Table 1: Standard Charges,,,,,,,,,,,,,,,,,,,,,
Last updated 02/11/2022,,,,,,,,,,,,,,,,,,,,,
Facility ID,Charge Code,Description,NDC/Supply ID,CPT(R)/HCPCS Code,Revenue Code,Gross Charge/Unit,Cash Price,Min Allowable,Max Allowable,Aetna (OP),Cigna Commercial (IP/OP),Health Alliance FI HMO/POS (IP/OP),Health Alliance Gated PPO (IP/OP),Health Alliance Non-Gated PPO (IP/OP),Health Alliance Public Exchange (OP),Health Alliance SF IERMP (IP/OP),Health Alliance SF P/CFH (IP/OP),Healthlink Commercial (IP/OP), Humana Choice Care (OP),PHCS PPO & Savility PPO (IP/OP),United Healthcare (IP/OP)
Hoopeston Regional Hlth Center,8980001,ketorolac 0.4 % eye drops,60758077305,,1,$332.63 ,$332.63 ,$93.14 ,$304.36 ,$232.84 ,$278.41 ,$304.36 ,$304.36 ,$304.36 ,$122.57 ,$199.58 ,$99.79 ,$299.37 ,$249.47 ,$266.10 ,$276.08
Hoopeston Regional Hlth Center,9010110,MED-SURG ROOM PRIVATE,,,110,"$2,980.00 ","$2,980.00 ",$834.40 ,"$2,726.70 ","$2,086.00 ","$2,494.26 ","$2,726.70 ","$2,726.70 ","$2,726.70 ","$1,098.13 ","$1,788.00 ",$894.00 ,"$2,682.00 ","$2,235.00 ","$2,384.00 ","$2,473.40 "
Hoopeston Regional Hlth Center,9010120,MED-SURG ROOM SEMI-PRIVATE,,,120,"$2,240.00 ","$2,240.00 ",$627.20 ,"$2,049.60 ","$1,568.00 ","$1,874.88 ","$2,049.60 ","$2,049.60 ","$2,049.60 ",$825.44 ,"$1,344.00 ",$672.00 ,"$2,016.00 ","$1,680.00 ","$1,792.00 ","$1,859.20 "
Hoopeston Regional Hlth Center,9011120,SKILLED SWING ROOM,,,120,"$1,340.00 ","$1,340.00 ",$375.20 ,"$1,226.10 ",$938.00 ,"$1,121.58 ","$1,226.10 ","$1,226.10 ","$1,226.10 ",$493.79 ,$804.00 ,$402.00 ,"$1,206.00 ","$1,005.00 ","$1,072.00 ","$1,112.20 "
Hoopeston Regional Hlth Center,9012120,INTERMEDIATE SWING,,,120,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9013120,RESPITE BED,,,120,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,8160003,ANESTHESIA MEDICATION,,,250,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9030001,TEGADERM 20X30 DRESSING,,,250,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9030002,HYDROPHILIC 4X8 FOAM DRESSING,,,250,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9650001,ALBUTEROL PREDILUTED CNS 3ML,,,250,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9650002,XOPENEX 0.63MG/3ML INH SOL,,,250,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9650003,ALBUTEROL SOLN 0.5ML,,,250,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9650004,ALUPENT 3ML SOLN,,,250,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9650005,BRETHINE 1MM VIAL,,,250,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9650006,INITIAL 2 ML NEB SOLUTION,,,250,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9650007,ATROVENT PREMIX SOLN,,,250,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9920002,TETANUS TOXOID ADSORBED,,,250,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9920003,DIPTHERIA/TETANUS TOXOID,,,250,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,8160005,OR ANESTHESIA MEDICATIONS 1,,,250,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,8160013,SEVOFLURANE,,,250,$3.00 ,$3.00 ,$0.84 ,$2.75 ,$2.10 ,$2.51 ,$2.75 ,$2.75 ,$2.75 ,$1.11 ,$1.80 ,$0.90 ,$2.70 ,$2.25 ,$2.40 ,$2.49
Hoopeston Regional Hlth Center,8160014,ISOFLURANE,,,250,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,8160015,NITROUS OXIDE,,,250,$3.00 ,$3.00 ,$0.84 ,$2.75 ,$2.10 ,$2.51 ,$2.75 ,$2.75 ,$2.75 ,$1.11 ,$1.80 ,$0.90 ,$2.70 ,$2.25 ,$2.40 ,$2.49
Hoopeston Regional Hlth Center,8980250,baricitinib 2 mg tablet,2418230,,250,$341.13 ,$341.13 ,$95.52 ,$312.13 ,$238.79 ,$285.53 ,$312.13 ,$312.13 ,$312.13 ,$125.71 ,$204.68 ,$102.34 ,$307.02 ,$255.85 ,$272.90 ,$283.14
Hoopeston Regional Hlth Center,8980250,insulin lispro protamine-lispro 100 unit/mL (75-25) subcutaneous pen,2879759,,250,$614.17 ,$614.17 ,$171.97 ,$561.97 ,$429.92 ,$514.06 ,$561.97 ,$561.97 ,$561.97 ,$226.32 ,$368.50 ,$184.25 ,$552.75 ,$460.63 ,$491.34 ,$509.76
Hoopeston Regional Hlth Center,8980250,"pediatric mv no.180-iron,carbonyl 8 mg-vit K 10 mcg chewable tablet",5423720,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,raltegravir 400 mg tablet,6022761,,250,$129.61 ,$129.61 ,$36.29 ,$118.59 ,$90.73 ,$108.48 ,$118.59 ,$118.59 ,$118.59 ,$47.76 ,$77.77 ,$38.88 ,$116.65 ,$97.21 ,$103.69 ,$107.58
Hoopeston Regional Hlth Center,8980250,imipenem-cilastatin 500 mg intravenous solution,6351659,J0743,250,$246.66 ,$246.66 ,$69.06 ,$225.69 ,$172.66 ,$206.45 ,$225.69 ,$225.69 ,$225.69 ,$90.89 ,$148.00 ,$74.00 ,$221.99 ,$185.00 ,$197.33 ,$204.73
Hoopeston Regional Hlth Center,8980250,"bacitracin 50,000 unit intramuscular solution",9023303,,250,$112.40 ,$112.40 ,$31.47 ,$102.85 ,$78.68 ,$94.08 ,$102.85 ,$102.85 ,$102.85 ,$41.42 ,$67.44 ,$33.72 ,$101.16 ,$84.30 ,$89.92 ,$93.29
Hoopeston Regional Hlth Center,8980250,"gelatin sponge,absorbable-porcine skin 12 mm-7 mm topical sponge",9031508,,250,$44.43 ,$44.43 ,$12.44 ,$40.65 ,$31.10 ,$37.19 ,$40.65 ,$40.65 ,$40.65 ,$16.37 ,$26.66 ,$13.33 ,$39.99 ,$33.32 ,$35.54 ,$36.88
Hoopeston Regional Hlth Center,8980250,"gelatin sponge,absorbable-porcine skin 100 topical sponge",9034201,,250,$183.98 ,$183.98 ,$51.51 ,$168.34 ,$128.79 ,$153.99 ,$168.34 ,$168.34 ,$168.34 ,$67.80 ,$110.39 ,$55.19 ,$165.58 ,$137.99 ,$147.18 ,$152.70
Hoopeston Regional Hlth Center,8980250,gelatin absorbable mucosal powder,9043304,,250,$327.77 ,$327.77 ,$91.78 ,$299.91 ,$229.44 ,$274.34 ,$299.91 ,$299.91 ,$299.91 ,$120.78 ,$196.66 ,$98.33 ,$294.99 ,$245.83 ,$262.22 ,$272.05
Hoopeston Regional Hlth Center,8980250,clindamycin 150 mg/mL injection solution,9087026,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,clindamycin 150 mg/mL injection solution,9090211,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,clindamycin 150 mg/mL injection solution,9090218,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,ketorolac (PF) 0.45 % eye drops in a dropperette,23350730,,250,$54.94 ,$54.94 ,$15.38 ,$50.27 ,$38.46 ,$45.98 ,$50.27 ,$50.27 ,$50.27 ,$20.25 ,$32.96 ,$16.48 ,$49.45 ,$41.21 ,$43.95 ,$45.60
Hoopeston Regional Hlth Center,8980250,"lipase-protease-amylase 5,000-17,000-24,000 unit capsule, delayed rel",23611501,,250,$12.98 ,$12.98 ,$3.63 ,$11.88 ,$9.09 ,$10.86 ,$11.88 ,$11.88 ,$11.88 ,$4.78 ,$7.79 ,$3.89 ,$11.68 ,$9.74 ,$10.38 ,$10.77
Hoopeston Regional Hlth Center,8980250,phenylephrine 1 % nasal spray,24135202,,250,$41.30 ,$41.30 ,$11.56 ,$37.79 ,$28.91 ,$34.57 ,$37.79 ,$37.79 ,$37.79 ,$15.22 ,$24.78 ,$12.39 ,$37.17 ,$30.98 ,$33.04 ,$34.28
Hoopeston Regional Hlth Center,8980250,primaquine 26.3 mg tablet,24159601,,250,$12.76 ,$12.76 ,$3.57 ,$11.68 ,$8.93 ,$10.68 ,$11.68 ,$11.68 ,$11.68 ,$4.70 ,$7.66 ,$3.83 ,$11.48 ,$9.57 ,$10.21 ,$10.59
Hoopeston Regional Hlth Center,8980250,"diclofenac 75 mg-misoprostoL 200 mcg tablet,immediate,delayed release",25142160,,250,$42.79 ,$42.79 ,$11.98 ,$39.15 ,$29.95 ,$35.82 ,$39.15 ,$39.15 ,$39.15 ,$15.77 ,$25.67 ,$12.84 ,$38.51 ,$32.09 ,$34.23 ,$35.52
Hoopeston Regional Hlth Center,8980250,"disopyramide phosphate ER 100 mg capsule,extended release",25273231,,250,$24.87 ,$24.87 ,$6.96 ,$22.76 ,$17.41 ,$20.82 ,$22.76 ,$22.76 ,$22.76 ,$9.16 ,$14.92 ,$7.46 ,$22.38 ,$18.65 ,$19.90 ,$20.64
Hoopeston Regional Hlth Center,8980250,"disopyramide phosphate ER 150 mg capsule,extended release",25274231,,250,$28.16 ,$28.16 ,$7.88 ,$25.77 ,$19.71 ,$23.57 ,$25.77 ,$25.77 ,$25.77 ,$10.38 ,$16.90 ,$8.45 ,$25.34 ,$21.12 ,$22.53 ,$23.37
Hoopeston Regional Hlth Center,8980250,"lipase-protease-amylase 6,000-19,000-30,000 unit capsule,delayed rel",32120601,,250,$12.26 ,$12.26 ,$3.43 ,$11.22 ,$8.58 ,$10.26 ,$11.22 ,$11.22 ,$11.22 ,$4.52 ,$7.36 ,$3.68 ,$11.03 ,$9.20 ,$9.81 ,$10.18
Hoopeston Regional Hlth Center,8980250,"lipase-protease-amylase 12,000-38,000-60,000 unit capsule,delayed rel",32121201,,250,$22.17 ,$22.17 ,$6.21 ,$20.29 ,$15.52 ,$18.56 ,$20.29 ,$20.29 ,$20.29 ,$8.17 ,$13.30 ,$6.65 ,$19.95 ,$16.63 ,$17.74 ,$18.40
Hoopeston Regional Hlth Center,8980250,"lipase-protease-amylase 24,000-76,000-120,000 unit capsule,delayed rel",32122401,,250,$37.68 ,$37.68 ,$10.55 ,$34.48 ,$26.38 ,$31.54 ,$34.48 ,$34.48 ,$34.48 ,$13.89 ,$22.61 ,$11.30 ,$33.91 ,$28.26 ,$30.14 ,$31.27
Hoopeston Regional Hlth Center,8980250,felbamate 400 mg tablet,37043001,,250,$61.24 ,$61.24 ,$17.15 ,$56.03 ,$42.87 ,$51.26 ,$56.03 ,$56.03 ,$56.03 ,$22.57 ,$36.74 ,$18.37 ,$55.12 ,$45.93 ,$48.99 ,$50.83
Hoopeston Regional Hlth Center,8980250,conjugated estrogens 0.3 mg tablet,46110081,,250,$34.19 ,$34.19 ,$9.57 ,$31.28 ,$23.93 ,$28.62 ,$31.28 ,$31.28 ,$31.28 ,$12.60 ,$20.51 ,$10.26 ,$30.77 ,$25.64 ,$27.35 ,$28.38
Hoopeston Regional Hlth Center,8980250,flecainide 100 mg tablet,54001121,,250,$10.67 ,$10.67 ,$2.99 ,$9.76 ,$7.47 ,$8.93 ,$9.76 ,$9.76 ,$9.76 ,$3.93 ,$6.40 ,$3.20 ,$9.60 ,$8.00 ,$8.54 ,$8.86
Hoopeston Regional Hlth Center,8980250,"lithium carbonate ER 450 mg tablet,extended release",54002025,,250,$4.83 ,$4.83 ,$1.35 ,$4.42 ,$3.38 ,$4.04 ,$4.42 ,$4.42 ,$4.42 ,$1.78 ,$2.90 ,$1.45 ,$4.35 ,$3.62 ,$3.86 ,$4.01
Hoopeston Regional Hlth Center,8980250,"lithium carbonate ER 300 mg tablet,extended release",54002125,,250,$4.50 ,$4.50 ,$1.26 ,$4.12 ,$3.15 ,$3.77 ,$4.12 ,$4.12 ,$4.12 ,$1.66 ,$2.70 ,$1.35 ,$4.05 ,$3.38 ,$3.60 ,$3.74
Hoopeston Regional Hlth Center,8980250,ipratropium bromide 21 mcg (0.03 %) nasal spray,54004544,,250,$541.31 ,$541.31 ,$151.57 ,$495.30 ,$378.92 ,$453.08 ,$495.30 ,$495.30 ,$495.30 ,$199.47 ,$324.79 ,$162.39 ,$487.18 ,$405.98 ,$433.05 ,$449.29
Hoopeston Regional Hlth Center,8980250,rOPINIRole 2 mg tablet,54011925,,250,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,8980250,OXcarbazepine 300 mg/5 mL (60 mg/mL) oral suspension,54019959,,250,$26.86 ,$26.86 ,$7.52 ,$24.58 ,$18.80 ,$22.48 ,$24.58 ,$24.58 ,$24.58 ,$9.90 ,$16.12 ,$8.06 ,$24.17 ,$20.15 ,$21.49 ,$22.29
Hoopeston Regional Hlth Center,8980250,morphine 15 mg immediate release tablet,54023524,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,codeine sulfate 30 mg tablet,54024424,,250,$9.46 ,$9.46 ,$2.65 ,$8.66 ,$6.62 ,$7.92 ,$8.66 ,$8.66 ,$8.66 ,$3.49 ,$5.68 ,$2.84 ,$8.51 ,$7.10 ,$7.57 ,$7.85
Hoopeston Regional Hlth Center,8980250,HYDROmorphone 1 mg/mL oral liquid,54038663,,250,$10.43 ,$10.43 ,$2.92 ,$9.54 ,$7.30 ,$8.73 ,$9.54 ,$9.54 ,$9.54 ,$3.84 ,$6.26 ,$3.13 ,$9.39 ,$7.82 ,$8.34 ,$8.66
Hoopeston Regional Hlth Center,8980250,morphine concentrate 100 mg/5 mL (20 mg/mL) oral solution,54040450,,250,$11.66 ,$11.66 ,$3.26 ,$10.67 ,$8.16 ,$9.76 ,$10.67 ,$10.67 ,$10.67 ,$4.30 ,$7.00 ,$3.50 ,$10.49 ,$8.75 ,$9.33 ,$9.68
Hoopeston Regional Hlth Center,8980250,morphine concentrate 100 mg/5 mL (20 mg/mL) oral solution,54051744,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,diphenoxylate-atropine 2.5 mg-0.025 mg/5 mL oral liquid,54319446,,250,$47.73 ,$47.73 ,$13.36 ,$43.67 ,$33.41 ,$39.95 ,$43.67 ,$43.67 ,$43.67 ,$17.59 ,$28.64 ,$14.32 ,$42.96 ,$35.80 ,$38.18 ,$39.62
Hoopeston Regional Hlth Center,8980250,lidocaine HCL 2 % mucosal solution,54350049,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,lithium citrate 8 mEq/5 mL oral solution,54352763,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,methadone 10 mg/mL oral concentrate,54355344,,250,$11.91 ,$11.91 ,$3.33 ,$10.90 ,$8.34 ,$9.97 ,$10.90 ,$10.90 ,$10.90 ,$4.39 ,$7.15 ,$3.57 ,$10.72 ,$8.93 ,$9.53 ,$9.89
Hoopeston Regional Hlth Center,8980250,methadone 5 mg/5 mL oral solution,54355563,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,Midazolam 2 mg/mL Syrup,54356699,,250,$68.65 ,$68.65 ,$19.22 ,$62.81 ,$48.06 ,$57.46 ,$62.81 ,$62.81 ,$62.81 ,$25.30 ,$41.19 ,$20.60 ,$61.79 ,$51.49 ,$54.92 ,$56.98
Hoopeston Regional Hlth Center,8980250,propranoloL 20 mg/5 mL (4 mg/mL) oral solution,54372763,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,furosemide 40 mg tablet,54429931,,250,$4.56 ,$4.56 ,$1.28 ,$4.17 ,$3.19 ,$3.82 ,$4.17 ,$4.17 ,$4.17 ,$1.68 ,$2.74 ,$1.37 ,$4.10 ,$3.42 ,$3.65 ,$3.78
Hoopeston Regional Hlth Center,8980250,lithium carbonate 300 mg tablet,54852825,,250,$3.53 ,$3.53 ,$0.99 ,$3.23 ,$2.47 ,$2.95 ,$3.23 ,$3.23 ,$3.23 ,$1.30 ,$2.12 ,$1.06 ,$3.18 ,$2.65 ,$2.82 ,$2.93
Hoopeston Regional Hlth Center,8980250,methadone 5 mg tablet,54855324,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,warfarin 1 mg tablet,56016975,,250,$13.86 ,$13.86 ,$3.88 ,$12.68 ,$9.70 ,$11.60 ,$12.68 ,$12.68 ,$12.68 ,$5.11 ,$8.32 ,$4.16 ,$12.47 ,$10.40 ,$11.09 ,$11.50
Hoopeston Regional Hlth Center,8980250,efavirenz 200 mg capsule,56047492,,250,$53.91 ,$53.91 ,$15.09 ,$49.33 ,$37.74 ,$45.12 ,$49.33 ,$49.33 ,$49.33 ,$19.87 ,$32.35 ,$16.17 ,$48.52 ,$40.43 ,$43.13 ,$44.75
Hoopeston Regional Hlth Center,8980250,"nepafenac 0.1 % eye drops,suspension",65000203,,250,"$1,539.94 ","$1,539.94 ",$431.18 ,"$1,409.05 ","$1,077.96 ","$1,288.93 ","$1,409.05 ","$1,409.05 ","$1,409.05 ",$567.47 ,$923.96 ,$461.98 ,"$1,385.95 ","$1,154.96 ","$1,231.95 ","$1,278.15 "
Hoopeston Regional Hlth Center,8980250,carbachoL 0.01 % intraocular solution,65002315,,250,$247.09 ,$247.09 ,$69.19 ,$226.09 ,$172.96 ,$206.81 ,$226.09 ,$226.09 ,$226.09 ,$91.05 ,$148.25 ,$74.13 ,$222.38 ,$185.32 ,$197.67 ,$205.08
Hoopeston Regional Hlth Center,8980250,fluorescein 500 mg/5 mL (10 %) intravenous solution,65009265,,250,$340.17 ,$340.17 ,$95.25 ,$311.26 ,$238.12 ,$284.72 ,$311.26 ,$311.26 ,$311.26 ,$125.35 ,$204.10 ,$102.05 ,$306.15 ,$255.13 ,$272.14 ,$282.34
Hoopeston Regional Hlth Center,8980250,atropine 1 % eye drops,65030355,,250,$291.30 ,$291.30 ,$81.56 ,$266.54 ,$203.91 ,$243.82 ,$266.54 ,$266.54 ,$266.54 ,$107.34 ,$174.78 ,$87.39 ,$262.17 ,$218.48 ,$233.04 ,$241.78
Hoopeston Regional Hlth Center,8980250,cyclopentolate-phenylephrine 0.2 %-1 % eye drops,65035902,,250,$182.02 ,$182.02 ,$50.97 ,$166.55 ,$127.41 ,$152.35 ,$166.55 ,$166.55 ,$166.55 ,$67.07 ,$109.21 ,$54.61 ,$163.82 ,$136.52 ,$145.62 ,$151.08
Hoopeston Regional Hlth Center,8980250,cyclopentolate-phenylephrine 0.2 %-1 % eye drops,65035905,,250,$303.88 ,$303.88 ,$85.09 ,$278.05 ,$212.72 ,$254.35 ,$278.05 ,$278.05 ,$278.05 ,$111.98 ,$182.33 ,$91.16 ,$273.49 ,$227.91 ,$243.10 ,$252.22
Hoopeston Regional Hlth Center,8980250,povidone-iodine 5 % eye solution,65041130,,250,$93.95 ,$93.95 ,$26.31 ,$85.96 ,$65.77 ,$78.64 ,$85.96 ,$85.96 ,$85.96 ,$34.62 ,$56.37 ,$28.19 ,$84.56 ,$70.46 ,$75.16 ,$77.98
Hoopeston Regional Hlth Center,8980250,"peg 400-hypromellose-glycerin 1 %-0.2 %-0.2 % eye drops,dextran 70-hypromellose 0.1 %-0.3 % eye drops,polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops,polyvinyl alcohol 1.4 % eye drops,peg 400-propylene glycol 0.4 %-0.3 % eye drops",65041881,,250,$45.40 ,$45.40 ,$12.71 ,$41.54 ,$31.78 ,$38.00 ,$41.54 ,$41.54 ,$41.54 ,$16.73 ,$27.24 ,$13.62 ,$40.86 ,$34.05 ,$36.32 ,$37.68
Hoopeston Regional Hlth Center,8980250,"white petrolatum-mineral oil 83 %-15 % eye ointment,white petrolatum 57.7 %-mineral oil 31.9 % eye ointment,white petrolatum-mineral oil 94 %-3 % eye ointment",65050935,,250,$53.30 ,$53.30 ,$14.92 ,$48.77 ,$37.31 ,$44.61 ,$48.77 ,$48.77 ,$48.77 ,$19.64 ,$31.98 ,$15.99 ,$47.97 ,$39.98 ,$42.64 ,$44.24
Hoopeston Regional Hlth Center,8980250,balanced salt solution non-surgical no.3 eye wash,65053001,J3490,250,$126.38 ,$126.38 ,$35.39 ,$115.64 ,$88.47 ,$105.78 ,$115.64 ,$115.64 ,$115.64 ,$46.57 ,$75.83 ,$37.91 ,$113.74 ,$94.79 ,$101.10 ,$104.90
Hoopeston Regional Hlth Center,8980250,balanced salt solution non-surgical no.3 eye wash,65053004,J3490,250,$182.02 ,$182.02 ,$50.97 ,$166.55 ,$127.41 ,$152.35 ,$166.55 ,$166.55 ,$166.55 ,$67.07 ,$109.21 ,$54.61 ,$163.82 ,$136.52 ,$145.62 ,$151.08
Hoopeston Regional Hlth Center,8980250,tobramycin 0.3 % eye ointment,65064435,,250,"$1,069.83 ","$1,069.83 ",$299.55 ,$978.89 ,$748.88 ,$895.45 ,$978.89 ,$978.89 ,$978.89 ,$394.23 ,$641.90 ,$320.95 ,$962.85 ,$802.37 ,$855.86 ,$887.96
Hoopeston Regional Hlth Center,8980250,ciprofloxacin 0.3 % eye ointment,65065435,,250,"$1,069.83 ","$1,069.83 ",$299.55 ,$978.89 ,$748.88 ,$895.45 ,$978.89 ,$978.89 ,$978.89 ,$394.23 ,$641.90 ,$320.95 ,$962.85 ,$802.37 ,$855.86 ,$887.96
Hoopeston Regional Hlth Center,8980250,apraclonidine 1 % eye drops in a dropperette,65066010,,250,$124.61 ,$124.61 ,$34.89 ,$114.02 ,$87.23 ,$104.30 ,$114.02 ,$114.02 ,$114.02 ,$45.92 ,$74.77 ,$37.38 ,$112.15 ,$93.46 ,$99.69 ,$103.43
Hoopeston Regional Hlth Center,8980250,tetracaine HCl (PF) 0.5 % eye drops,65074114,,250,$77.46 ,$77.46 ,$21.69 ,$70.88 ,$54.22 ,$64.83 ,$70.88 ,$70.88 ,$70.88 ,$28.54 ,$46.48 ,$23.24 ,$69.71 ,$58.10 ,$61.97 ,$64.29
Hoopeston Regional Hlth Center,8980250,moxifloxacin 0.5 % eye drops,65401303,,250,$994.64 ,$994.64 ,$278.50 ,$910.10 ,$696.25 ,$832.51 ,$910.10 ,$910.10 ,$910.10 ,$366.52 ,$596.78 ,$298.39 ,$895.18 ,$745.98 ,$795.71 ,$825.55
Hoopeston Regional Hlth Center,8980250,"ciprofloxacin 0.3 %-dexamethasone 0.1 % ear drops,suspension",65853302,,250,"$1,413.90 ","$1,413.90 ",$395.89 ,"$1,293.72 ",$989.73 ,"$1,183.43 ","$1,293.72 ","$1,293.72 ","$1,293.72 ",$521.02 ,$848.34 ,$424.17 ,"$1,272.51 ","$1,060.43 ","$1,131.12 ","$1,173.54 "
Hoopeston Regional Hlth Center,8980250,terbinafine HCL 1 % topical cream,67810030,,250,$81.20 ,$81.20 ,$22.74 ,$74.30 ,$56.84 ,$67.96 ,$74.30 ,$74.30 ,$74.30 ,$29.92 ,$48.72 ,$24.36 ,$73.08 ,$60.90 ,$64.96 ,$67.40
Hoopeston Regional Hlth Center,8980250,varenicline 1 mg tablet,69046956,,250,$42.32 ,$42.32 ,$11.85 ,$38.72 ,$29.62 ,$35.42 ,$38.72 ,$38.72 ,$38.72 ,$15.59 ,$25.39 ,$12.70 ,$38.09 ,$31.74 ,$33.86 ,$35.13
Hoopeston Regional Hlth Center,8980250,dofetilide 125 mcg capsule,69580043,,250,$52.02 ,$52.02 ,$14.57 ,$47.60 ,$36.41 ,$43.54 ,$47.60 ,$47.60 ,$47.60 ,$19.17 ,$31.21 ,$15.61 ,$46.82 ,$39.02 ,$41.62 ,$43.18
Hoopeston Regional Hlth Center,8980250,ritonavir 100 mg tablet,74333330,,250,$44.15 ,$44.15 ,$12.36 ,$40.40 ,$30.91 ,$36.95 ,$40.40 ,$40.40 ,$40.40 ,$16.27 ,$26.49 ,$13.25 ,$39.74 ,$33.11 ,$35.32 ,$36.64
Hoopeston Regional Hlth Center,8980250,"divalproex ER 250 mg tablet,extended release 24 hr",74382611,,250,$21.09 ,$21.09 ,$5.91 ,$19.30 ,$14.76 ,$17.65 ,$19.30 ,$19.30 ,$19.30 ,$7.77 ,$12.65 ,$6.33 ,$18.98 ,$15.82 ,$16.87 ,$17.50
Hoopeston Regional Hlth Center,8980250,lopinavir-ritonavir 400 mg-100 mg/5 mL oral solution,74395646,,250,$118.76 ,$118.76 ,$33.25 ,$108.67 ,$83.13 ,$99.40 ,$108.67 ,$108.67 ,$108.67 ,$43.76 ,$71.26 ,$35.63 ,$106.88 ,$89.07 ,$95.01 ,$98.57
Hoopeston Regional Hlth Center,8980250,lopinavir-ritonavir 200 mg-50 mg tablet,74679922,,250,$79.84 ,$79.84 ,$22.36 ,$73.05 ,$55.89 ,$66.83 ,$73.05 ,$73.05 ,$73.05 ,$29.42 ,$47.90 ,$23.95 ,$71.86 ,$59.88 ,$63.87 ,$66.27
Hoopeston Regional Hlth Center,8980250,entacapone 200 mg tablet,78032705,,250,$40.54 ,$40.54 ,$11.35 ,$37.09 ,$28.38 ,$33.93 ,$37.09 ,$37.09 ,$37.09 ,$14.94 ,$24.32 ,$12.16 ,$36.49 ,$30.41 ,$32.43 ,$33.65
Hoopeston Regional Hlth Center,8980250,estradioL 0.05 mg/24 hr semiweekly transdermal patch,78034445,,250,$71.85 ,$71.85 ,$20.12 ,$65.74 ,$50.30 ,$60.14 ,$65.74 ,$65.74 ,$65.74 ,$26.48 ,$43.11 ,$21.56 ,$64.67 ,$53.89 ,$57.48 ,$59.64
Hoopeston Regional Hlth Center,8980250,estradioL 0.075 mg/24 hr semiweekly transdermal patch,78034542,,250,$78.24 ,$78.24 ,$21.91 ,$71.59 ,$54.77 ,$65.49 ,$71.59 ,$71.59 ,$71.59 ,$28.83 ,$46.94 ,$23.47 ,$70.42 ,$58.68 ,$62.59 ,$64.94
Hoopeston Regional Hlth Center,8980250,estradioL 0.1 mg/24 hr semiweekly transdermal patch,78034645,,250,$71.94 ,$71.94 ,$20.14 ,$65.83 ,$50.36 ,$60.21 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.16 ,$21.58 ,$64.75 ,$53.96 ,$57.55 ,$59.71
Hoopeston Regional Hlth Center,8980250,imatinib 100 mg tablet,78040134,S0088,250,$231.47 ,$231.47 ,$64.81 ,$211.80 ,$162.03 ,$193.74 ,$211.80 ,$211.80 ,$211.80 ,$85.30 ,$138.88 ,$69.44 ,$208.32 ,$173.60 ,$185.18 ,$192.12
Hoopeston Regional Hlth Center,8980250,"white petrolatum-mineral oil 83 %-15 % eye ointment,white petrolatum 57.7 %-mineral oil 31.9 % eye ointment,white petrolatum-mineral oil 94 %-3 % eye ointment",78047397,,250,$44.65 ,$44.65 ,$12.50 ,$40.85 ,$31.26 ,$37.37 ,$40.85 ,$40.85 ,$40.85 ,$16.45 ,$26.79 ,$13.40 ,$40.19 ,$33.49 ,$35.72 ,$37.06
Hoopeston Regional Hlth Center,8980250,rivastigmine 4.6 mg/24 hour transdermal patch,78050115,,250,$104.19 ,$104.19 ,$29.17 ,$95.33 ,$72.93 ,$87.21 ,$95.33 ,$95.33 ,$95.33 ,$38.39 ,$62.51 ,$31.26 ,$93.77 ,$78.14 ,$83.35 ,$86.48
Hoopeston Regional Hlth Center,8980250,posaconazole 200 mg/5 mL (40 mg/mL) oral suspension,85132801,,250,$254.46 ,$254.46 ,$71.25 ,$232.83 ,$178.12 ,$212.98 ,$232.83 ,$232.83 ,$232.83 ,$93.77 ,$152.68 ,$76.34 ,$229.01 ,$190.85 ,$203.57 ,$211.20
Hoopeston Regional Hlth Center,8980250,mometasone 220 mcg/actuation(14 doses) breath activated powder inhaler,85134106,,250,$434.55 ,$434.55 ,$121.67 ,$397.61 ,$304.19 ,$363.72 ,$397.61 ,$397.61 ,$397.61 ,$160.13 ,$260.73 ,$130.37 ,$391.10 ,$325.91 ,$347.64 ,$360.68
Hoopeston Regional Hlth Center,8980250,pediatric multivitamin no.192 250 mcg-50 mg-10 mcg/mL oral drops,87040203,,250,$56.75 ,$56.75 ,$15.89 ,$51.93 ,$39.73 ,$47.50 ,$51.93 ,$51.93 ,$51.93 ,$20.91 ,$34.05 ,$17.03 ,$51.08 ,$42.56 ,$45.40 ,$47.10
Hoopeston Regional Hlth Center,8980250,"didanosine 250 mg capsule,delayed release",87667317,,250,$46.68 ,$46.68 ,$13.07 ,$42.71 ,$32.68 ,$39.07 ,$42.71 ,$42.71 ,$42.71 ,$17.20 ,$28.01 ,$14.00 ,$42.01 ,$35.01 ,$37.34 ,$38.74
Hoopeston Regional Hlth Center,8980250,venlafaxine 25 mg tablet,93019901,,250,$11.38 ,$11.38 ,$3.19 ,$10.41 ,$7.97 ,$9.53 ,$10.41 ,$10.41 ,$10.41 ,$4.19 ,$6.83 ,$3.41 ,$10.24 ,$8.54 ,$9.10 ,$9.45
Hoopeston Regional Hlth Center,8980250,loperamide 2 mg capsule,93031105,,250,$8.54 ,$8.54 ,$2.39 ,$7.81 ,$5.98 ,$7.15 ,$7.81 ,$7.81 ,$7.81 ,$3.15 ,$5.12 ,$2.56 ,$7.69 ,$6.41 ,$6.83 ,$7.09
Hoopeston Regional Hlth Center,8980250,ketorolac 10 mg tablet,93031401,,250,$12.38 ,$12.38 ,$3.47 ,$11.33 ,$8.67 ,$10.36 ,$11.33 ,$11.33 ,$11.33 ,$4.56 ,$7.43 ,$3.71 ,$11.14 ,$9.29 ,$9.90 ,$10.28
Hoopeston Regional Hlth Center,8980250,dilTIAZem 60 mg tablet,93031905,,250,$9.50 ,$9.50 ,$2.66 ,$8.69 ,$6.65 ,$7.95 ,$8.69 ,$8.69 ,$8.69 ,$3.50 ,$5.70 ,$2.85 ,$8.55 ,$7.13 ,$7.60 ,$7.89
Hoopeston Regional Hlth Center,8980250,atenoloL 25 mg tablet,93078701,,250,$6.14 ,$6.14 ,$1.72 ,$5.62 ,$4.30 ,$5.14 ,$5.62 ,$5.62 ,$5.62 ,$2.26 ,$3.68 ,$1.84 ,$5.53 ,$4.61 ,$4.91 ,$5.10
Hoopeston Regional Hlth Center,8980250,neomycin 500 mg tablet,93117701,,250,$8.69 ,$8.69 ,$2.43 ,$7.95 ,$6.08 ,$7.27 ,$7.95 ,$7.95 ,$7.95 ,$3.20 ,$5.21 ,$2.61 ,$7.82 ,$6.52 ,$6.95 ,$7.21
Hoopeston Regional Hlth Center,8980250,azithromycin 100 mg/5 mL oral suspension,93202723,,250,$74.65 ,$74.65 ,$20.90 ,$68.30 ,$52.26 ,$62.48 ,$68.30 ,$68.30 ,$68.30 ,$27.51 ,$44.79 ,$22.40 ,$67.19 ,$55.99 ,$59.72 ,$61.96
Hoopeston Regional Hlth Center,8980250,metoclopramide 10 mg tablet,93220305,,250,$3.55 ,$3.55 ,$0.99 ,$3.25 ,$2.49 ,$2.97 ,$3.25 ,$3.25 ,$3.25 ,$1.31 ,$2.13 ,$1.07 ,$3.20 ,$2.66 ,$2.84 ,$2.95
Hoopeston Regional Hlth Center,8980250,amoxicillin 250 mg capsule,93310701,,250,$3.50 ,$3.50 ,$0.98 ,$3.20 ,$2.45 ,$2.93 ,$3.20 ,$3.20 ,$3.20 ,$1.29 ,$2.10 ,$1.05 ,$3.15 ,$2.63 ,$2.80 ,$2.91
Hoopeston Regional Hlth Center,8980250,disopyramide phosphate 100 mg capsule,93312701,,250,$15.64 ,$15.64 ,$4.38 ,$14.31 ,$10.95 ,$13.09 ,$14.31 ,$14.31 ,$14.31 ,$5.76 ,$9.38 ,$4.69 ,$14.08 ,$11.73 ,$12.51 ,$12.98
Hoopeston Regional Hlth Center,8980250,disopyramide phosphate 150 mg capsule,93312901,,250,$18.06 ,$18.06 ,$5.06 ,$16.52 ,$12.64 ,$15.12 ,$16.52 ,$16.52 ,$16.52 ,$6.66 ,$10.84 ,$5.42 ,$16.25 ,$13.55 ,$14.45 ,$14.99
Hoopeston Regional Hlth Center,8980250,cephalexin 500 mg capsule,93314701,,250,$8.74 ,$8.74 ,$2.45 ,$8.00 ,$6.12 ,$7.32 ,$8.00 ,$8.00 ,$8.00 ,$3.22 ,$5.24 ,$2.62 ,$7.87 ,$6.56 ,$6.99 ,$7.25
Hoopeston Regional Hlth Center,8980250,cefdinir 300 mg capsule,93316006,,250,$26.05 ,$26.05 ,$7.29 ,$23.84 ,$18.24 ,$21.80 ,$23.84 ,$23.84 ,$23.84 ,$9.60 ,$15.63 ,$7.82 ,$23.45 ,$19.54 ,$20.84 ,$21.62
Hoopeston Regional Hlth Center,8980250,prazosin 5 mg capsule,93406901,,250,$13.02 ,$13.02 ,$3.65 ,$11.91 ,$9.11 ,$10.90 ,$11.91 ,$11.91 ,$11.91 ,$4.80 ,$7.81 ,$3.91 ,$11.72 ,$9.77 ,$10.42 ,$10.81
Hoopeston Regional Hlth Center,8980250,cephalexin 125 mg/5 mL oral suspension,93417573,,250,$13.92 ,$13.92 ,$3.90 ,$12.74 ,$9.74 ,$11.65 ,$12.74 ,$12.74 ,$12.74 ,$5.13 ,$8.35 ,$4.18 ,$12.53 ,$10.44 ,$11.14 ,$11.55
Hoopeston Regional Hlth Center,8980250,bumetanide 2 mg tablet,93423401,,250,$13.36 ,$13.36 ,$3.74 ,$12.22 ,$9.35 ,$11.18 ,$12.22 ,$12.22 ,$12.22 ,$4.92 ,$8.02 ,$4.01 ,$12.02 ,$10.02 ,$10.69 ,$11.09
Hoopeston Regional Hlth Center,8980250,"oxybutynin chloride ER 10 mg tablet,extended release 24 hr",93520701,,250,$17.67 ,$17.67 ,$4.95 ,$16.17 ,$12.37 ,$14.79 ,$16.17 ,$16.17 ,$16.17 ,$6.51 ,$10.60 ,$5.30 ,$15.90 ,$13.25 ,$14.14 ,$14.67
Hoopeston Regional Hlth Center,8980250,solifenacin 5 mg tablet,93526356,,250,$59.42 ,$59.42 ,$16.64 ,$54.37 ,$41.59 ,$49.73 ,$54.37 ,$54.37 ,$54.37 ,$21.90 ,$35.65 ,$17.83 ,$53.48 ,$44.57 ,$47.54 ,$49.32
Hoopeston Regional Hlth Center,8980250,progesterone micronized 100 mg capsule,93535301,,250,$12.27 ,$12.27 ,$3.44 ,$11.23 ,$8.59 ,$10.27 ,$11.23 ,$11.23 ,$11.23 ,$4.52 ,$7.36 ,$3.68 ,$11.04 ,$9.20 ,$9.82 ,$10.18
Hoopeston Regional Hlth Center,8980250,progesterone micronized 200 mg capsule,93535401,,250,$21.20 ,$21.20 ,$5.94 ,$19.40 ,$14.84 ,$17.74 ,$19.40 ,$19.40 ,$19.40 ,$7.81 ,$12.72 ,$6.36 ,$19.08 ,$15.90 ,$16.96 ,$17.60
Hoopeston Regional Hlth Center,8980250,"esomeprazole magnesium 20 mg capsule,delayed release",93645056,,250,$53.10 ,$53.10 ,$14.87 ,$48.59 ,$37.17 ,$44.44 ,$48.59 ,$48.59 ,$48.59 ,$19.57 ,$31.86 ,$15.93 ,$47.79 ,$39.83 ,$42.48 ,$44.07
Hoopeston Regional Hlth Center,8980250,"tolterodine ER 2 mg capsule,extended release 24 hr",93716356,,250,$36.28 ,$36.28 ,$10.16 ,$33.20 ,$25.40 ,$30.37 ,$33.20 ,$33.20 ,$33.20 ,$13.37 ,$21.77 ,$10.88 ,$32.65 ,$27.21 ,$29.02 ,$30.11
Hoopeston Regional Hlth Center,8980250,"tolterodine ER 4 mg capsule,extended release 24 hr",93716456,,250,$36.28 ,$36.28 ,$10.16 ,$33.20 ,$25.40 ,$30.37 ,$33.20 ,$33.20 ,$33.20 ,$13.37 ,$21.77 ,$10.88 ,$32.65 ,$27.21 ,$29.02 ,$30.11
Hoopeston Regional Hlth Center,8980250,pravastatin 20 mg tablet,93720198,,250,$17.55 ,$17.55 ,$4.91 ,$16.06 ,$12.29 ,$14.69 ,$16.06 ,$16.06 ,$16.06 ,$6.47 ,$10.53 ,$5.27 ,$15.80 ,$13.16 ,$14.04 ,$14.57
Hoopeston Regional Hlth Center,8980250,fosinopriL 10 mg tablet,93722298,,250,$11.76 ,$11.76 ,$3.29 ,$10.76 ,$8.23 ,$9.84 ,$10.76 ,$10.76 ,$10.76 ,$4.33 ,$7.06 ,$3.53 ,$10.58 ,$8.82 ,$9.41 ,$9.76
Hoopeston Regional Hlth Center,8980250,venlafaxine 37.5 mg tablet,93738001,,250,$11.65 ,$11.65 ,$3.26 ,$10.66 ,$8.16 ,$9.75 ,$10.66 ,$10.66 ,$10.66 ,$4.29 ,$6.99 ,$3.50 ,$10.49 ,$8.74 ,$9.32 ,$9.67
Hoopeston Regional Hlth Center,8980250,venlafaxine 50 mg tablet,93738101,,250,$11.93 ,$11.93 ,$3.34 ,$10.92 ,$8.35 ,$9.99 ,$10.92 ,$10.92 ,$10.92 ,$4.40 ,$7.16 ,$3.58 ,$10.74 ,$8.95 ,$9.54 ,$9.90
Hoopeston Regional Hlth Center,8980250,venlafaxine 75 mg tablet,93738201,,250,$12.51 ,$12.51 ,$3.50 ,$11.45 ,$8.76 ,$10.47 ,$11.45 ,$11.45 ,$11.45 ,$4.61 ,$7.51 ,$3.75 ,$11.26 ,$9.38 ,$10.01 ,$10.38
Hoopeston Regional Hlth Center,8980250,montelukast 4 mg chewable tablet,93742456,,250,$27.95 ,$27.95 ,$7.83 ,$25.57 ,$19.57 ,$23.39 ,$25.57 ,$25.57 ,$25.57 ,$10.30 ,$16.77 ,$8.39 ,$25.16 ,$20.96 ,$22.36 ,$23.20
Hoopeston Regional Hlth Center,8980250,cimetidine 400 mg tablet,93820401,,250,$17.88 ,$17.88 ,$5.01 ,$16.36 ,$12.52 ,$14.97 ,$16.36 ,$16.36 ,$16.36 ,$6.59 ,$10.73 ,$5.36 ,$16.09 ,$13.41 ,$14.30 ,$14.84
Hoopeston Regional Hlth Center,8980250,amoxicillin 600 mg-potassium clavulanate 42.9 mg/5 mL oral suspension,93867578,,250,$21.89 ,$21.89 ,$6.13 ,$20.03 ,$15.32 ,$18.32 ,$20.03 ,$20.03 ,$20.03 ,$8.07 ,$13.13 ,$6.57 ,$19.70 ,$16.42 ,$17.51 ,$18.17
Hoopeston Regional Hlth Center,8980250,mexiletine 150 mg capsule,93873901,,250,$14.15 ,$14.15 ,$3.96 ,$12.95 ,$9.91 ,$11.84 ,$12.95 ,$12.95 ,$12.95 ,$5.21 ,$8.49 ,$4.25 ,$12.74 ,$10.61 ,$11.32 ,$11.74
Hoopeston Regional Hlth Center,8980250,mexiletine 200 mg capsule,93874001,,250,$16.44 ,$16.44 ,$4.60 ,$15.04 ,$11.51 ,$13.76 ,$15.04 ,$15.04 ,$15.04 ,$6.06 ,$9.86 ,$4.93 ,$14.80 ,$12.33 ,$13.15 ,$13.65
Hoopeston Regional Hlth Center,8980250,pyridostigmine bromide 60 mg tablet,115351101,,250,$8.27 ,$8.27 ,$2.32 ,$7.57 ,$5.79 ,$6.92 ,$7.57 ,$7.57 ,$7.57 ,$3.05 ,$4.96 ,$2.48 ,$7.44 ,$6.20 ,$6.62 ,$6.86
Hoopeston Regional Hlth Center,8980250,dantrolene 25 mg capsule,115441101,,250,$7.31 ,$7.31 ,$2.05 ,$6.69 ,$5.12 ,$6.12 ,$6.69 ,$6.69 ,$6.69 ,$2.69 ,$4.39 ,$2.19 ,$6.58 ,$5.48 ,$5.85 ,$6.07
Hoopeston Regional Hlth Center,8980250,magnesium hydroxide 400 mg/5 mL oral suspension,121043130,,250,$1.64 ,$1.64 ,$0.46 ,$1.50 ,$1.15 ,$1.37 ,$1.50 ,$1.50 ,$1.50 ,$0.60 ,$0.98 ,$0.49 ,$1.48 ,$1.23 ,$1.31 ,$1.36
Hoopeston Regional Hlth Center,8980250,diphenhydrAMINE 12.5 mg/5 mL oral elixir,121048900,,250,$5.01 ,$5.01 ,$1.40 ,$4.58 ,$3.51 ,$4.19 ,$4.58 ,$4.58 ,$4.58 ,$1.85 ,$3.01 ,$1.50 ,$4.51 ,$3.76 ,$4.01 ,$4.16
Hoopeston Regional Hlth Center,8980250,ferrous sulfate 300 mg (60 mg iron)/5 mL oral liquid,121053005,,250,$30.68 ,$30.68 ,$8.59 ,$28.07 ,$21.48 ,$25.68 ,$28.07 ,$28.07 ,$28.07 ,$11.31 ,$18.41 ,$9.20 ,$27.61 ,$23.01 ,$24.54 ,$25.46
Hoopeston Regional Hlth Center,8980250,metoclopramide 5 mg/5 mL oral solution,121057616,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,haloperidol lactate 2 mg/mL oral concentrate,121058104,,250,$9.62 ,$9.62 ,$2.69 ,$8.80 ,$6.73 ,$8.05 ,$8.80 ,$8.80 ,$8.80 ,$3.54 ,$5.77 ,$2.89 ,$8.66 ,$7.22 ,$7.70 ,$7.98
Hoopeston Regional Hlth Center,8980250,sodium citrate-citric acid 500 mg-334 mg/5 mL oral solution,121059515,,250,$20.64 ,$20.64 ,$5.78 ,$18.89 ,$14.45 ,$17.28 ,$18.89 ,$18.89 ,$18.89 ,$7.61 ,$12.38 ,$6.19 ,$18.58 ,$15.48 ,$16.51 ,$17.13
Hoopeston Regional Hlth Center,8980250,dextromethorphan-guaifenesin 10 mg-100 mg/5 mL oral syrup,121063805,,250,$3.49 ,$3.49 ,$0.98 ,$3.19 ,$2.44 ,$2.92 ,$3.19 ,$3.19 ,$3.19 ,$1.29 ,$2.09 ,$1.05 ,$3.14 ,$2.62 ,$2.79 ,$2.90
Hoopeston Regional Hlth Center,8980250,valproic acid (as sodium salt) 250 mg/5 mL oral solution,121067516,,250,$11.38 ,$11.38 ,$3.19 ,$10.41 ,$7.97 ,$9.53 ,$10.41 ,$10.41 ,$10.41 ,$4.19 ,$6.83 ,$3.41 ,$10.24 ,$8.54 ,$9.10 ,$9.45
Hoopeston Regional Hlth Center,8980250,acetaminophen 300 mg-codeine 30 mg/12.5 mL (12.5 mL) oral solution,121100800,,250,$12.82 ,$12.82 ,$3.59 ,$11.73 ,$8.97 ,$10.73 ,$11.73 ,$11.73 ,$11.73 ,$4.72 ,$7.69 ,$3.85 ,$11.54 ,$9.62 ,$10.26 ,$10.64
Hoopeston Regional Hlth Center,8980250,lactulose 20 gram/30 mL oral solution,121115400,,250,$6.10 ,$6.10 ,$1.71 ,$5.58 ,$4.27 ,$5.11 ,$5.58 ,$5.58 ,$5.58 ,$2.25 ,$3.66 ,$1.83 ,$5.49 ,$4.58 ,$4.88 ,$5.06
Hoopeston Regional Hlth Center,8980250,guaiFENesin 100 mg/5 mL oral liquid,121148800,,250,$0.90 ,$0.90 ,$0.25 ,$0.82 ,$0.63 ,$0.75 ,$0.82 ,$0.82 ,$0.82 ,$0.33 ,$0.54 ,$0.27 ,$0.81 ,$0.68 ,$0.72 ,$0.75
Hoopeston Regional Hlth Center,8980250,Metoclopramide 5 mg/5 mL Oral Soln,121157610,,250,$19.97 ,$19.97 ,$5.59 ,$18.27 ,$13.98 ,$16.71 ,$18.27 ,$18.27 ,$18.27 ,$7.36 ,$11.98 ,$5.99 ,$17.97 ,$14.98 ,$15.98 ,$16.58
Hoopeston Regional Hlth Center,8980250,aluminum-mag hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral susp,121176130,,250,$5.29 ,$5.29 ,$1.48 ,$4.84 ,$3.70 ,$4.43 ,$4.84 ,$4.84 ,$4.84 ,$1.95 ,$3.17 ,$1.59 ,$4.76 ,$3.97 ,$4.23 ,$4.39
Hoopeston Regional Hlth Center,8980250,codeine 10 mg-guaifenesin 100 mg/5 mL oral liquid,121177505,J3490,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,senna leaf extract 176 mg/5 mL oral syrup,121472215,,250,$35.10 ,$35.10 ,$9.83 ,$32.12 ,$24.57 ,$29.38 ,$32.12 ,$32.12 ,$32.12 ,$12.93 ,$21.06 ,$10.53 ,$31.59 ,$26.33 ,$28.08 ,$29.13
Hoopeston Regional Hlth Center,8980250,megestroL 400 mg/10 mL (10 mL) oral suspension,121477600,,250,$44.64 ,$44.64 ,$12.50 ,$40.85 ,$31.25 ,$37.36 ,$40.85 ,$40.85 ,$40.85 ,$16.45 ,$26.78 ,$13.39 ,$40.18 ,$33.48 ,$35.71 ,$37.05
Hoopeston Regional Hlth Center,8980250,sodium phosphates 19 gram-7 gram/118 mL enema,132020140,,250,$2.42 ,$2.42 ,$0.68 ,$2.21 ,$1.69 ,$2.03 ,$2.21 ,$2.21 ,$2.21 ,$0.89 ,$1.45 ,$0.73 ,$2.18 ,$1.82 ,$1.94 ,$2.01
Hoopeston Regional Hlth Center,8980250,sodium phosphates 9.5 gram-3.5 gram/59 mL enema,132020220,,250,$2.13 ,$2.13 ,$0.60 ,$1.95 ,$1.49 ,$1.78 ,$1.95 ,$1.95 ,$1.95 ,$0.78 ,$1.28 ,$0.64 ,$1.92 ,$1.60 ,$1.70 ,$1.77
Hoopeston Regional Hlth Center,8980250,captopriL 25 mg tablet,143117201,,250,$10.11 ,$10.11 ,$2.83 ,$9.25 ,$7.08 ,$8.46 ,$9.25 ,$9.25 ,$9.25 ,$3.73 ,$6.07 ,$3.03 ,$9.10 ,$7.58 ,$8.09 ,$8.39
Hoopeston Regional Hlth Center,8980250,digoxin 125 mcg (0.125 mg) tablet,143124001,,250,$13.05 ,$13.05 ,$3.65 ,$11.94 ,$9.14 ,$10.92 ,$11.94 ,$11.94 ,$11.94 ,$4.81 ,$7.83 ,$3.92 ,$11.75 ,$9.79 ,$10.44 ,$10.83
Hoopeston Regional Hlth Center,8980250,PHENobarbitaL 30 mg tablet,143145005,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,PHENobarbitaL 60 mg tablet,143145505,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,isosorbide dinitrate 20 mg tablet,143177201,,250,$7.88 ,$7.88 ,$2.21 ,$7.21 ,$5.52 ,$6.60 ,$7.21 ,$7.21 ,$7.21 ,$2.90 ,$4.73 ,$2.36 ,$7.09 ,$5.91 ,$6.30 ,$6.54
Hoopeston Regional Hlth Center,8980250,etomidate 2 mg/mL intravenous solution,143950710,,250,$50.31 ,$50.31 ,$14.09 ,$46.03 ,$35.22 ,$42.11 ,$46.03 ,$46.03 ,$46.03 ,$18.54 ,$30.19 ,$15.09 ,$45.28 ,$37.73 ,$40.25 ,$41.76
Hoopeston Regional Hlth Center,8980250,ketamine 100 mg/mL injection solution,143950910,,250,$86.81 ,$86.81 ,$24.31 ,$79.43 ,$60.77 ,$72.66 ,$79.43 ,$79.43 ,$79.43 ,$31.99 ,$52.09 ,$26.04 ,$78.13 ,$65.11 ,$69.45 ,$72.05
Hoopeston Regional Hlth Center,8980250,Glycopyrrolate 0.2 mg/mL Injection,143968225,,250,$52.29 ,$52.29 ,$14.64 ,$47.85 ,$36.60 ,$43.77 ,$47.85 ,$47.85 ,$47.85 ,$19.27 ,$31.37 ,$15.69 ,$47.06 ,$39.22 ,$41.83 ,$43.40
Hoopeston Regional Hlth Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,143968225,J3490,250,$52.29 ,$52.29 ,$14.64 ,$47.85 ,$36.60 ,$43.77 ,$47.85 ,$47.85 ,$47.85 ,$19.27 ,$31.37 ,$15.69 ,$47.06 ,$39.22 ,$41.83 ,$43.40
Hoopeston Regional Hlth Center,8980250,niCARdipine 25 mg/10 mL intravenous solution,143968910,,250,$213.16 ,$213.16 ,$59.68 ,$195.04 ,$149.21 ,$178.41 ,$195.04 ,$195.04 ,$195.04 ,$78.55 ,$127.90 ,$63.95 ,$191.84 ,$159.87 ,$170.53 ,$176.92
Hoopeston Regional Hlth Center,8980250,enalaprilat 1.25 mg/mL intravenous solution,143978710,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,amoxicillin 600 mg-potassium clavulanate 42.9 mg/5 mL oral suspension,143985375,,250,$21.83 ,$21.83 ,$6.11 ,$19.97 ,$15.28 ,$18.27 ,$19.97 ,$19.97 ,$19.97 ,$8.04 ,$13.10 ,$6.55 ,$19.65 ,$16.37 ,$17.46 ,$18.12
Hoopeston Regional Hlth Center,8980250,triamcinolone acetonide 0.5 % topical cream,168000215,,250,$68.10 ,$68.10 ,$19.07 ,$62.31 ,$47.67 ,$57.00 ,$62.31 ,$62.31 ,$62.31 ,$25.09 ,$40.86 ,$20.43 ,$61.29 ,$51.08 ,$54.48 ,$56.52
Hoopeston Regional Hlth Center,8980250,triamcinolone acetonide 0.1 % topical cream,168000416,J3490,250,$133.12 ,$133.12 ,$37.27 ,$121.80 ,$93.18 ,$111.42 ,$121.80 ,$121.80 ,$121.80 ,$49.05 ,$79.87 ,$39.94 ,$119.81 ,$99.84 ,$106.50 ,$110.49
Hoopeston Regional Hlth Center,8980250,triamcinolone acetonide 0.1 % topical cream,168000480,J3490,250,$52.39 ,$52.39 ,$14.67 ,$47.94 ,$36.67 ,$43.85 ,$47.94 ,$47.94 ,$47.94 ,$19.31 ,$31.43 ,$15.72 ,$47.15 ,$39.29 ,$41.91 ,$43.48
Hoopeston Regional Hlth Center,8980250,hydrocortisone 1 % topical cream,168001516,,250,$357.06 ,$357.06 ,$99.98 ,$326.71 ,$249.94 ,$298.86 ,$326.71 ,$326.71 ,$326.71 ,$131.58 ,$214.24 ,$107.12 ,$321.35 ,$267.80 ,$285.65 ,$296.36
Hoopeston Regional Hlth Center,8980250,zinc oxide 20 % topical ointment,168006216,,250,$245.25 ,$245.25 ,$68.67 ,$224.40 ,$171.68 ,$205.27 ,$224.40 ,$224.40 ,$224.40 ,$90.37 ,$147.15 ,$73.58 ,$220.73 ,$183.94 ,$196.20 ,$203.56
Hoopeston Regional Hlth Center,8980250,zinc oxide 20 % topical ointment,168006231,,250,$21.69 ,$21.69 ,$6.07 ,$19.85 ,$15.18 ,$18.15 ,$19.85 ,$19.85 ,$19.85 ,$7.99 ,$13.01 ,$6.51 ,$19.52 ,$16.27 ,$17.35 ,$18.00
Hoopeston Regional Hlth Center,8980250,clobetasoL 0.05 % topical cream,168016315,,250,$618.55 ,$618.55 ,$173.19 ,$565.97 ,$432.99 ,$517.73 ,$565.97 ,$565.97 ,$565.97 ,$227.94 ,$371.13 ,$185.57 ,$556.70 ,$463.91 ,$494.84 ,$513.40
Hoopeston Regional Hlth Center,8980250,lidocaine 5 % topical ointment,168020437,J3490,250,"$1,418.97 ","$1,418.97 ",$397.31 ,"$1,298.36 ",$993.28 ,"$1,187.68 ","$1,298.36 ","$1,298.36 ","$1,298.36 ",$522.89 ,$851.38 ,$425.69 ,"$1,277.07 ","$1,064.23 ","$1,135.18 ","$1,177.75 "
Hoopeston Regional Hlth Center,8980250,insulin human U-100 NPH-regulr 70-30 mix 100 unit/mL subcutaneous susp,169183711,J1815,250,$965.10 ,$965.10 ,$270.23 ,$883.07 ,$675.57 ,$807.79 ,$883.07 ,$883.07 ,$883.07 ,$355.64 ,$579.06 ,$289.53 ,$868.59 ,$723.83 ,$772.08 ,$801.03
Hoopeston Regional Hlth Center,8980250,insulin detemir (U-100) 100 unit/mL (3 mL) subcutaneous pen,169643810,,250,$537.91 ,$537.91 ,$150.61 ,$492.19 ,$376.54 ,$450.23 ,$492.19 ,$492.19 ,$492.19 ,$198.22 ,$322.75 ,$161.37 ,$484.12 ,$403.43 ,$430.33 ,$446.47
Hoopeston Regional Hlth Center,8980250,insulin aspart U-100 100 unit/mL subcutaneous solution,169750111,J1815,250,$45.42 ,$45.42 ,$12.72 ,$41.56 ,$31.79 ,$38.02 ,$41.56 ,$41.56 ,$41.56 ,$16.74 ,$27.25 ,$13.63 ,$40.88 ,$34.07 ,$36.34 ,$37.70
Hoopeston Regional Hlth Center,8980250,insulin aspart U-100 100 unit/mL subcutaneous solution,169750111,J1815,250,"$1,655.42 ","$1,655.42 ",$463.52 ,"$1,514.71 ","$1,158.79 ","$1,385.59 ","$1,514.71 ","$1,514.71 ","$1,514.71 ",$610.02 ,$993.25 ,$496.63 ,"$1,489.88 ","$1,241.57 ","$1,324.34 ","$1,374.00 "
Hoopeston Regional Hlth Center,8980250,famotidine 20 mg tablet,172572880,,250,$13.62 ,$13.62 ,$3.81 ,$12.46 ,$9.53 ,$11.40 ,$12.46 ,$12.46 ,$12.46 ,$5.02 ,$8.17 ,$4.09 ,$12.26 ,$10.22 ,$10.90 ,$11.30
Hoopeston Regional Hlth Center,8980250,zanamivir 5 mg/actuation blister powder for inhalation,173068101,,250,$482.06 ,$482.06 ,$134.98 ,$441.08 ,$337.44 ,$403.48 ,$441.08 ,$441.08 ,$441.08 ,$177.64 ,$289.24 ,$144.62 ,$433.85 ,$361.55 ,$385.65 ,$400.11
Hoopeston Regional Hlth Center,8980250,fluticasone furoate 100 mcg-vilanteroL 25 mcg/dose inhalation powder,173085914,,250,"$1,100.69 ","$1,100.69 ",$308.19 ,"$1,007.13 ",$770.48 ,$921.28 ,"$1,007.13 ","$1,007.13 ","$1,007.13 ",$405.60 ,$660.41 ,$330.21 ,$990.62 ,$825.52 ,$880.55 ,$913.57
Hoopeston Regional Hlth Center,8980250,umeclidinium 62.5 mcg-vilanteroL 25 mcg/actuation powdr for inhalation,173086906,,250,$778.41 ,$778.41 ,$217.95 ,$712.25 ,$544.89 ,$651.53 ,$712.25 ,$712.25 ,$712.25 ,$286.84 ,$467.05 ,$233.52 ,$700.57 ,$583.81 ,$622.73 ,$646.08
Hoopeston Regional Hlth Center,8980250,fluticasone furoate 200 mcg-vilanteroL 25 mcg/dose inhalation powder,173088214,,250,$39.31 ,$39.31 ,$11.01 ,$35.97 ,$27.52 ,$32.90 ,$35.97 ,$35.97 ,$35.97 ,$14.49 ,$23.59 ,$11.79 ,$35.38 ,$29.48 ,$31.45 ,$32.63
Hoopeston Regional Hlth Center,8980250,"potassium citrate ER 10 mEq (1,080 mg) tablet,extended release",178061001,,250,$14.29 ,$14.29 ,$4.00 ,$13.08 ,$10.00 ,$11.96 ,$13.08 ,$13.08 ,$13.08 ,$5.27 ,$8.57 ,$4.29 ,$12.86 ,$10.72 ,$11.43 ,$11.86
Hoopeston Regional Hlth Center,8980250,lovastatin 40 mg tablet,185007401,,250,$22.23 ,$22.23 ,$6.22 ,$20.34 ,$15.56 ,$18.61 ,$20.34 ,$20.34 ,$20.34 ,$8.19 ,$13.34 ,$6.67 ,$20.01 ,$16.67 ,$17.78 ,$18.45
Hoopeston Regional Hlth Center,8980250,nitrofurantoin monohydrate/macrocrystals 100 mg capsule,185012201,,250,$17.28 ,$17.28 ,$4.84 ,$15.81 ,$12.10 ,$14.46 ,$15.81 ,$15.81 ,$15.81 ,$6.37 ,$10.37 ,$5.18 ,$15.55 ,$12.96 ,$13.82 ,$14.34
Hoopeston Regional Hlth Center,8980250,bumetanide 1 mg tablet,185012901,,250,$7.41 ,$7.41 ,$2.07 ,$6.78 ,$5.19 ,$6.20 ,$6.78 ,$6.78 ,$6.78 ,$2.73 ,$4.45 ,$2.22 ,$6.67 ,$5.56 ,$5.93 ,$6.15
Hoopeston Regional Hlth Center,8980250,bumetanide 2 mg tablet,185013001,,250,$11.76 ,$11.76 ,$3.29 ,$10.76 ,$8.23 ,$9.84 ,$10.76 ,$10.76 ,$10.76 ,$4.33 ,$7.06 ,$3.53 ,$10.58 ,$8.82 ,$9.41 ,$9.76
Hoopeston Regional Hlth Center,8980250,methIMAzole 5 mg tablet,185020501,,250,$4.40 ,$4.40 ,$1.23 ,$4.03 ,$3.08 ,$3.68 ,$4.03 ,$4.03 ,$4.03 ,$1.62 ,$2.64 ,$1.32 ,$3.96 ,$3.30 ,$3.52 ,$3.65
Hoopeston Regional Hlth Center,8980250,sulfADIAZINE 500 mg tablet,185075701,,250,$25.81 ,$25.81 ,$7.23 ,$23.62 ,$18.07 ,$21.60 ,$23.62 ,$23.62 ,$23.62 ,$9.51 ,$15.49 ,$7.74 ,$23.23 ,$19.36 ,$20.65 ,$21.42
Hoopeston Regional Hlth Center,8980250,benazepriL 20 mg tablet,185082001,,250,$7.03 ,$7.03 ,$1.97 ,$6.43 ,$4.92 ,$5.88 ,$6.43 ,$6.43 ,$6.43 ,$2.59 ,$4.22 ,$2.11 ,$6.33 ,$5.27 ,$5.62 ,$5.83
Hoopeston Regional Hlth Center,8980250,ticagrelor 90 mg tablet,186077760,,250,$37.05 ,$37.05 ,$10.37 ,$33.90 ,$25.94 ,$31.01 ,$33.90 ,$33.90 ,$33.90 ,$13.65 ,$22.23 ,$11.12 ,$33.35 ,$27.79 ,$29.64 ,$30.75
Hoopeston Regional Hlth Center,8980250,pyridostigmine bromide 60 mg/5 mL oral syrup,187301220,,250,$108.37 ,$108.37 ,$30.34 ,$99.16 ,$75.86 ,$90.71 ,$99.16 ,$99.16 ,$99.16 ,$39.93 ,$65.02 ,$32.51 ,$97.53 ,$81.28 ,$86.70 ,$89.95
Hoopeston Regional Hlth Center,8980250,isoproterenoL 0.2 mg/mL injection solution,187433005,,250,"$10,074.38 ","$10,074.38 ","$2,820.83 ","$9,218.06 ","$7,052.07 ","$8,432.26 ","$9,218.06 ","$9,218.06 ","$9,218.06 ","$3,712.41 ","$6,044.63 ","$3,022.31 ","$9,066.94 ","$7,555.79 ","$8,059.50 ","$8,361.74 "
Hoopeston Regional Hlth Center,8980250,sodium chloride 0.65 % nasal drops,225055050,,250,$34.94 ,$34.94 ,$9.78 ,$31.97 ,$24.46 ,$29.24 ,$31.97 ,$31.97 ,$31.97 ,$12.88 ,$20.96 ,$10.48 ,$31.45 ,$26.21 ,$27.95 ,$29.00
Hoopeston Regional Hlth Center,8980250,ALPRAZolam 0.25 mg tablet,228202750,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,cloNIDine HCL 0.1 mg tablet,228212750,,250,$3.51 ,$3.51 ,$0.98 ,$3.21 ,$2.46 ,$2.94 ,$3.21 ,$3.21 ,$3.21 ,$1.29 ,$2.11 ,$1.05 ,$3.16 ,$2.63 ,$2.81 ,$2.91
Hoopeston Regional Hlth Center,8980250,cloNIDine HCL 0.2 mg tablet,228212850,,250,$4.04 ,$4.04 ,$1.13 ,$3.70 ,$2.83 ,$3.38 ,$3.70 ,$3.70 ,$3.70 ,$1.49 ,$2.42 ,$1.21 ,$3.64 ,$3.03 ,$3.23 ,$3.35
Hoopeston Regional Hlth Center,8980250,propylthiouraciL 50 mg tablet,228234810,,250,$6.52 ,$6.52 ,$1.83 ,$5.97 ,$4.56 ,$5.46 ,$5.97 ,$5.97 ,$5.97 ,$2.40 ,$3.91 ,$1.96 ,$5.87 ,$4.89 ,$5.22 ,$5.41
Hoopeston Regional Hlth Center,8980250,NIFEdipine 10 mg capsule,228249710,,250,$7.31 ,$7.31 ,$2.05 ,$6.69 ,$5.12 ,$6.12 ,$6.69 ,$6.69 ,$6.69 ,$2.69 ,$4.39 ,$2.19 ,$6.58 ,$5.48 ,$5.85 ,$6.07
Hoopeston Regional Hlth Center,8980250,"diclofenac sodium 50 mg tablet,delayed release",228255006,,250,$6.74 ,$6.74 ,$1.89 ,$6.17 ,$4.72 ,$5.64 ,$6.17 ,$6.17 ,$6.17 ,$2.48 ,$4.04 ,$2.02 ,$6.07 ,$5.06 ,$5.39 ,$5.59
Hoopeston Regional Hlth Center,8980250,"propranoloL ER 80 mg capsule,24 hr,extended release",228277911,,250,$13.55 ,$13.55 ,$3.79 ,$12.40 ,$9.49 ,$11.34 ,$12.40 ,$12.40 ,$12.40 ,$4.99 ,$8.13 ,$4.07 ,$12.20 ,$10.16 ,$10.84 ,$11.25
Hoopeston Regional Hlth Center,8980250,"propranoloL ER 120 mg capsule,24 hr,extended release",228278011,,250,$16.23 ,$16.23 ,$4.54 ,$14.85 ,$11.36 ,$13.58 ,$14.85 ,$14.85 ,$14.85 ,$5.98 ,$9.74 ,$4.87 ,$14.61 ,$12.17 ,$12.98 ,$13.47
Hoopeston Regional Hlth Center,8980250,"propranoloL ER 160 mg capsule,24 hr,extended release",228278111,,250,$20.53 ,$20.53 ,$5.75 ,$18.78 ,$14.37 ,$17.18 ,$18.78 ,$18.78 ,$18.78 ,$7.57 ,$12.32 ,$6.16 ,$18.48 ,$15.40 ,$16.42 ,$17.04
Hoopeston Regional Hlth Center,8980250,midodrine 5 mg tablet,245021211,,250,$21.70 ,$21.70 ,$6.08 ,$19.86 ,$15.19 ,$18.16 ,$19.86 ,$19.86 ,$19.86 ,$8.00 ,$13.02 ,$6.51 ,$19.53 ,$16.28 ,$17.36 ,$18.01
Hoopeston Regional Hlth Center,8980250,midodrine 10 mg tablet,245021311,,250,$42.17 ,$42.17 ,$11.81 ,$38.59 ,$29.52 ,$35.30 ,$38.59 ,$38.59 ,$38.59 ,$15.54 ,$25.30 ,$12.65 ,$37.95 ,$31.63 ,$33.74 ,$35.00
Hoopeston Regional Hlth Center,8980250,colchicine 0.6 mg tablet,254200801,,250,$31.73 ,$31.73 ,$8.88 ,$29.03 ,$22.21 ,$26.56 ,$29.03 ,$29.03 ,$29.03 ,$11.69 ,$19.04 ,$9.52 ,$28.56 ,$23.80 ,$25.38 ,$26.34
Hoopeston Regional Hlth Center,8980250,surgical lubricant jelly topical,281020537,,250,$31.15 ,$31.15 ,$8.72 ,$28.50 ,$21.81 ,$26.07 ,$28.50 ,$28.50 ,$28.50 ,$11.48 ,$18.69 ,$9.35 ,$28.04 ,$23.36 ,$24.92 ,$25.85
Hoopeston Regional Hlth Center,8980250,nitroglycerin 2 % transdermal ointment,281032608,,250,$15.17 ,$15.17 ,$4.25 ,$13.88 ,$10.62 ,$12.70 ,$13.88 ,$13.88 ,$13.88 ,$5.59 ,$9.10 ,$4.55 ,$13.65 ,$11.38 ,$12.14 ,$12.59
Hoopeston Regional Hlth Center,8980250,sodium zirconium cyclosilicate 10 gram oral powder packet,310111039,,250,$107.32 ,$107.32 ,$30.05 ,$98.20 ,$75.12 ,$89.83 ,$98.20 ,$98.20 ,$98.20 ,$39.55 ,$64.39 ,$32.20 ,$96.59 ,$80.49 ,$85.86 ,$89.08
Hoopeston Regional Hlth Center,8980250,naloxegoL 25 mg tablet,310197030,,250,$57.90 ,$57.90 ,$16.21 ,$52.98 ,$40.53 ,$48.46 ,$52.98 ,$52.98 ,$52.98 ,$21.34 ,$34.74 ,$17.37 ,$52.11 ,$43.43 ,$46.32 ,$48.06
Hoopeston Regional Hlth Center,8980250,camphor-menthoL 0.5 %-0.5 % lotion,316022975,,250,$52.60 ,$52.60 ,$14.73 ,$48.13 ,$36.82 ,$44.03 ,$48.13 ,$48.13 ,$48.13 ,$19.38 ,$31.56 ,$15.78 ,$47.34 ,$39.45 ,$42.08 ,$43.66
Hoopeston Regional Hlth Center,8980250,nitroglycerin 50 mg/250 mL (200 mcg/mL) in 5 % dextrose intravenous,338104902,,250,$153.27 ,$153.27 ,$42.92 ,$140.24 ,$107.29 ,$128.29 ,$140.24 ,$140.24 ,$140.24 ,$56.48 ,$91.96 ,$45.98 ,$137.94 ,$114.95 ,$122.62 ,$127.21
Hoopeston Regional Hlth Center,8980250,metroNIDAZOLE 500 mg/100 mL-sodium chloride(iso) intravenous piggyback,338105548,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,clindamycin 300 mg/50 mL in 0.9% sodium chloride intravenous piggyback,338954524,,250,$52.87 ,$52.87 ,$14.80 ,$48.38 ,$37.01 ,$44.25 ,$48.38 ,$48.38 ,$48.38 ,$19.48 ,$31.72 ,$15.86 ,$47.58 ,$39.65 ,$42.30 ,$43.88
Hoopeston Regional Hlth Center,8980250,clindamycin 600 mg/50 mL in 0.9% sodium chloride intravenous piggyback,338954924,,250,$77.90 ,$77.90 ,$21.81 ,$71.28 ,$54.53 ,$65.20 ,$71.28 ,$71.28 ,$71.28 ,$28.71 ,$46.74 ,$23.37 ,$70.11 ,$58.43 ,$62.32 ,$64.66
Hoopeston Regional Hlth Center,8980250,pindoloL 5 mg tablet,378005201,,250,$8.48 ,$8.48 ,$2.37 ,$7.76 ,$5.94 ,$7.10 ,$7.76 ,$7.76 ,$7.76 ,$3.12 ,$5.09 ,$2.54 ,$7.63 ,$6.36 ,$6.78 ,$7.04
Hoopeston Regional Hlth Center,8980250,pindoloL 10 mg tablet,378012701,,250,$10.71 ,$10.71 ,$3.00 ,$9.80 ,$7.50 ,$8.96 ,$9.80 ,$9.80 ,$9.80 ,$3.95 ,$6.43 ,$3.21 ,$9.64 ,$8.03 ,$8.57 ,$8.89
Hoopeston Regional Hlth Center,8980250,atenoloL 50 mg tablet,378023101,,250,$6.28 ,$6.28 ,$1.76 ,$5.75 ,$4.40 ,$5.26 ,$5.75 ,$5.75 ,$5.75 ,$2.31 ,$3.77 ,$1.88 ,$5.65 ,$4.71 ,$5.02 ,$5.21
Hoopeston Regional Hlth Center,8980250,furosemide 80 mg tablet,378023201,,250,$4.55 ,$4.55 ,$1.27 ,$4.16 ,$3.19 ,$3.81 ,$4.16 ,$4.16 ,$4.16 ,$1.68 ,$2.73 ,$1.37 ,$4.10 ,$3.41 ,$3.64 ,$3.78
Hoopeston Regional Hlth Center,8980250,"NIFEdipine ER 30 mg tablet,extended release",378035301,,250,$8.83 ,$8.83 ,$2.47 ,$8.08 ,$6.18 ,$7.39 ,$8.08 ,$8.08 ,$8.08 ,$3.25 ,$5.30 ,$2.65 ,$7.95 ,$6.62 ,$7.06 ,$7.33
Hoopeston Regional Hlth Center,8980250,levothyroxine 75 mcg tablet,378180510,,250,$4.88 ,$4.88 ,$1.37 ,$4.47 ,$3.42 ,$4.08 ,$4.47 ,$4.47 ,$4.47 ,$1.80 ,$2.93 ,$1.46 ,$4.39 ,$3.66 ,$3.90 ,$4.05
Hoopeston Regional Hlth Center,8980250,meclofenamate 50 mg capsule,378215001,,250,$21.75 ,$21.75 ,$6.09 ,$19.90 ,$15.23 ,$18.20 ,$19.90 ,$19.90 ,$19.90 ,$8.01 ,$13.05 ,$6.53 ,$19.58 ,$16.31 ,$17.40 ,$18.05
Hoopeston Regional Hlth Center,8980250,terazosin 1 mg capsule,378226001,,250,$9.81 ,$9.81 ,$2.75 ,$8.98 ,$6.87 ,$8.21 ,$8.98 ,$8.98 ,$8.98 ,$3.61 ,$5.89 ,$2.94 ,$8.83 ,$7.36 ,$7.85 ,$8.14
Hoopeston Regional Hlth Center,8980250,terazosin 2 mg capsule,378226401,,250,$9.81 ,$9.81 ,$2.75 ,$8.98 ,$6.87 ,$8.21 ,$8.98 ,$8.98 ,$8.98 ,$3.61 ,$5.89 ,$2.94 ,$8.83 ,$7.36 ,$7.85 ,$8.14
Hoopeston Regional Hlth Center,8980250,estradioL 0.05 mg/24 hr weekly transdermal patch,378335099,,250,$89.38 ,$89.38 ,$25.03 ,$81.78 ,$62.57 ,$74.81 ,$81.78 ,$81.78 ,$81.78 ,$32.94 ,$53.63 ,$26.81 ,$80.44 ,$67.04 ,$71.50 ,$74.19
Hoopeston Regional Hlth Center,8980250,estradioL 0.1 mg/24 hr weekly transdermal patch,378335299,,250,$89.38 ,$89.38 ,$25.03 ,$81.78 ,$62.57 ,$74.81 ,$81.78 ,$81.78 ,$81.78 ,$32.94 ,$53.63 ,$26.81 ,$80.44 ,$67.04 ,$71.50 ,$74.19
Hoopeston Regional Hlth Center,8980250,estradioL 0.06 mg/24 hr weekly transdermal patch,378336199,,250,$89.38 ,$89.38 ,$25.03 ,$81.78 ,$62.57 ,$74.81 ,$81.78 ,$81.78 ,$81.78 ,$32.94 ,$53.63 ,$26.81 ,$80.44 ,$67.04 ,$71.50 ,$74.19
Hoopeston Regional Hlth Center,8980250,clopidogreL 75 mg tablet,378362705,,250,$32.48 ,$32.48 ,$9.09 ,$29.72 ,$22.74 ,$27.19 ,$29.72 ,$29.72 ,$29.72 ,$11.97 ,$19.49 ,$9.74 ,$29.23 ,$24.36 ,$25.98 ,$26.96
Hoopeston Regional Hlth Center,8980250,abacavir 300 mg tablet,378410591,,250,$43.30 ,$43.30 ,$12.12 ,$39.62 ,$30.31 ,$36.24 ,$39.62 ,$39.62 ,$39.62 ,$15.96 ,$25.98 ,$12.99 ,$38.97 ,$32.48 ,$34.64 ,$35.94
Hoopeston Regional Hlth Center,8980250,"dilTIAZem ER 60 mg capsule,extended release 12 hr",378606001,,250,$17.11 ,$17.11 ,$4.79 ,$15.66 ,$11.98 ,$14.32 ,$15.66 ,$15.66 ,$15.66 ,$6.31 ,$10.27 ,$5.13 ,$15.40 ,$12.83 ,$13.69 ,$14.20
Hoopeston Regional Hlth Center,8980250,"dilTIAZem ER 90 mg capsule,extended release 12 hr",378609001,,250,$19.22 ,$19.22 ,$5.38 ,$17.59 ,$13.45 ,$16.09 ,$17.59 ,$17.59 ,$17.59 ,$7.08 ,$11.53 ,$5.77 ,$17.30 ,$14.42 ,$15.38 ,$15.95
Hoopeston Regional Hlth Center,8980250,metOLazone 2.5 mg tablet,378617201,,250,$14.34 ,$14.34 ,$4.02 ,$13.12 ,$10.04 ,$12.00 ,$13.12 ,$13.12 ,$13.12 ,$5.28 ,$8.60 ,$4.30 ,$12.91 ,$10.76 ,$11.47 ,$11.90
Hoopeston Regional Hlth Center,8980250,"pantoprazole 20 mg tablet,delayed release",378668877,,250,$26.58 ,$26.58 ,$7.44 ,$24.32 ,$18.61 ,$22.25 ,$24.32 ,$24.32 ,$24.32 ,$9.79 ,$15.95 ,$7.97 ,$23.92 ,$19.94 ,$21.26 ,$22.06
Hoopeston Regional Hlth Center,8980250,"pantoprazole 40 mg tablet,delayed release",378668910,,250,$26.58 ,$26.58 ,$7.44 ,$24.32 ,$18.61 ,$22.25 ,$24.32 ,$24.32 ,$24.32 ,$9.79 ,$15.95 ,$7.97 ,$23.92 ,$19.94 ,$21.26 ,$22.06
Hoopeston Regional Hlth Center,8980250,sodium chloride 0.9 % for nebulization,378698601,J3490,250,$4.31 ,$4.31 ,$1.21 ,$3.94 ,$3.02 ,$3.61 ,$3.94 ,$3.94 ,$3.94 ,$1.59 ,$2.59 ,$1.29 ,$3.88 ,$3.23 ,$3.45 ,$3.58
Hoopeston Regional Hlth Center,8980250,loxapine succinate 10 mg capsule,378701001,,250,$8.26 ,$8.26 ,$2.31 ,$7.56 ,$5.78 ,$6.91 ,$7.56 ,$7.56 ,$7.56 ,$3.04 ,$4.96 ,$2.48 ,$7.43 ,$6.20 ,$6.61 ,$6.86
Hoopeston Regional Hlth Center,8980250,fenofibrate 54 mg tablet,378710077,,250,$6.02 ,$6.02 ,$1.69 ,$5.51 ,$4.21 ,$5.04 ,$5.51 ,$5.51 ,$5.51 ,$2.22 ,$3.61 ,$1.81 ,$5.42 ,$4.52 ,$4.82 ,$5.00
Hoopeston Regional Hlth Center,8980250,nitroglycerin 0.1 mg/hr transdermal 24 hour patch,378910293,,250,$10.99 ,$10.99 ,$3.08 ,$10.06 ,$7.69 ,$9.20 ,$10.06 ,$10.06 ,$10.06 ,$4.05 ,$6.59 ,$3.30 ,$9.89 ,$8.24 ,$8.79 ,$9.12
Hoopeston Regional Hlth Center,8980250,fentaNYL 100 mcg/hr transdermal patch,378912416,,250,$197.25 ,$197.25 ,$55.23 ,$180.48 ,$138.08 ,$165.10 ,$180.48 ,$180.48 ,$180.48 ,$72.69 ,$118.35 ,$59.18 ,$177.53 ,$147.94 ,$157.80 ,$163.72
Hoopeston Regional Hlth Center,8980250,fentaNYL 100 mcg/hr transdermal patch,378912498,,250,$197.25 ,$197.25 ,$55.23 ,$180.48 ,$138.08 ,$165.10 ,$180.48 ,$180.48 ,$180.48 ,$72.69 ,$118.35 ,$59.18 ,$177.53 ,$147.94 ,$157.80 ,$163.72
Hoopeston Regional Hlth Center,8980250,ethyl chloride 100 % topical spray,386000103,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,compounding vehicle syrup no.23,395009016,,250,$103.34 ,$103.34 ,$28.94 ,$94.56 ,$72.34 ,$86.50 ,$94.56 ,$94.56 ,$94.56 ,$38.08 ,$62.00 ,$31.00 ,$93.01 ,$77.51 ,$82.67 ,$85.77
Hoopeston Regional Hlth Center,8980250,glycerin 99.5 % topical solution,395103116,,250,$13.98 ,$13.98 ,$3.91 ,$12.79 ,$9.79 ,$11.70 ,$12.79 ,$12.79 ,$12.79 ,$5.15 ,$8.39 ,$4.19 ,$12.58 ,$10.49 ,$11.18 ,$11.60
Hoopeston Regional Hlth Center,8980250,HYDROcodone 5 mg-acetaminophen 325 mg tablet,406012301,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,HYDROcodone 7.5 mg-acetaminophen 325 mg tablet,406012462,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,acetaminophen 300 mg-codeine 30 mg tablet,406048462,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,oxyCODONE 5 mg tablet,406055262,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,methylphenidate 10 mg tablet,406114401,,250,$9.52 ,$9.52 ,$2.67 ,$8.71 ,$6.66 ,$7.97 ,$8.71 ,$8.71 ,$8.71 ,$3.51 ,$5.71 ,$2.86 ,$8.57 ,$7.14 ,$7.62 ,$7.90
Hoopeston Regional Hlth Center,8980250,morphine concentrate 100 mg/5 mL (20 mg/mL) oral solution,406800312,,250,$11.15 ,$11.15 ,$3.12 ,$10.20 ,$7.81 ,$9.33 ,$10.20 ,$10.20 ,$10.20 ,$4.11 ,$6.69 ,$3.35 ,$10.04 ,$8.36 ,$8.92 ,$9.25
Hoopeston Regional Hlth Center,8980250,"morphine ER 15 mg tablet,extended release",406831501,,250,$12.47 ,$12.47 ,$3.49 ,$11.41 ,$8.73 ,$10.44 ,$11.41 ,$11.41 ,$11.41 ,$4.60 ,$7.48 ,$3.74 ,$11.22 ,$9.35 ,$9.98 ,$10.35
Hoopeston Regional Hlth Center,8980250,"morphine ER 30 mg tablet,extended release",406833062,,250,$20.41 ,$20.41 ,$5.71 ,$18.68 ,$14.29 ,$17.08 ,$18.68 ,$18.68 ,$18.68 ,$7.52 ,$12.25 ,$6.12 ,$18.37 ,$15.31 ,$16.33 ,$16.94
Hoopeston Regional Hlth Center,8980250,fentaNYL 100 mcg/hr transdermal patch,406900076,,250,$197.25 ,$197.25 ,$55.23 ,$180.48 ,$138.08 ,$165.10 ,$180.48 ,$180.48 ,$180.48 ,$72.69 ,$118.35 ,$59.18 ,$177.53 ,$147.94 ,$157.80 ,$163.72
Hoopeston Regional Hlth Center,8980250,fentaNYL 50 mcg/hr transdermal patch,406905076,,250,$102.75 ,$102.75 ,$28.77 ,$94.02 ,$71.93 ,$86.00 ,$94.02 ,$94.02 ,$94.02 ,$37.86 ,$61.65 ,$30.83 ,$92.48 ,$77.06 ,$82.20 ,$85.28
Hoopeston Regional Hlth Center,8980250,bupivacaine (PF) 0.5 % (5 mg/mL) injection solution,409116201,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,bupivacaine (PF) 0.5 % (5 mg/mL) injection solution,409116202,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,bupivacaine HCl 0.5 % (5 mg/mL) injection solution,409116301,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,dilTIAZem 5 mg/mL intravenous solution,409117101,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,meperidine 100 mg/mL injection solution,409120120,J2175,250,$816.43 ,$816.43 ,$228.60 ,$747.03 ,$571.50 ,$683.35 ,$747.03 ,$747.03 ,$747.03 ,$300.85 ,$489.86 ,$244.93 ,$734.79 ,$612.32 ,$653.14 ,$677.64
Hoopeston Regional Hlth Center,8980250,isoproterenoL 0.2 mg/mL injection solution,409141001,,250,$287.19 ,$287.19 ,$80.41 ,$262.78 ,$201.03 ,$240.38 ,$262.78 ,$262.78 ,$262.78 ,$105.83 ,$172.31 ,$86.16 ,$258.47 ,$215.39 ,$229.75 ,$238.37
Hoopeston Regional Hlth Center,8980250,bumetanide 0.25 mg/mL injection solution,409141204,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,bupivacaine (PF) 0.25 % (2.5 mg/mL) injection solution,409155910,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,bupivacaine (PF) 0.75 % (7.5 mg/mL) injection solution,409158210,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,bupivacaine (PF) 0.75 % (7.5 mg/mL) injection solution,409158229,J3490,250,$46.88 ,$46.88 ,$13.13 ,$42.90 ,$32.82 ,$39.24 ,$42.90 ,$42.90 ,$42.90 ,$17.28 ,$28.13 ,$14.06 ,$42.19 ,$35.16 ,$37.50 ,$38.91
Hoopeston Regional Hlth Center,8980250,"bupivacaine-epinephrine 0.25 %-1:200,000 injection solution",409175250,,250,$73.24 ,$73.24 ,$20.51 ,$67.01 ,$51.27 ,$61.30 ,$67.01 ,$67.01 ,$67.01 ,$26.99 ,$43.94 ,$21.97 ,$65.92 ,$54.93 ,$58.59 ,$60.79
Hoopeston Regional Hlth Center,8980250,dextrose 25 % in water (D25W) intravenous syringe,409177510,,250,$70.50 ,$70.50 ,$19.74 ,$64.51 ,$49.35 ,$59.01 ,$64.51 ,$64.51 ,$64.51 ,$25.98 ,$42.30 ,$21.15 ,$63.45 ,$52.88 ,$56.40 ,$58.52
Hoopeston Regional Hlth Center,8980250,labetaloL 5 mg/mL intravenous solution,409226720,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,fenoldopam 10 mg/mL intravenous solution,409230401,,250,"$9,528.06 ","$9,528.06 ","$2,667.86 ","$8,718.17 ","$6,669.64 ","$7,974.99 ","$8,718.17 ","$8,718.17 ","$8,718.17 ","$3,511.09 ","$5,716.84 ","$2,858.42 ","$8,575.25 ","$7,146.05 ","$7,622.45 ","$7,908.29 "
Hoopeston Regional Hlth Center,8980250,"lidocaine-epinephrine 0.5 %-1:200,000 injection solution",409317701,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,"lidocaine 1 %-epinephrine 1:100,000 injection solution",409317801,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,"lidocaine 20 mg/mL (2 %)-epinephrine 1:100,000 injection solution",409318201,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,sodium acetate 2 mEq/mL intravenous solution,409329905,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,norepinephrine bitartrate 1 mg/mL intravenous solution,409337504,,250,$176.24 ,$176.24 ,$49.35 ,$161.26 ,$123.37 ,$147.51 ,$161.26 ,$161.26 ,$161.26 ,$64.94 ,$105.74 ,$52.87 ,$158.62 ,$132.18 ,$140.99 ,$146.28
Hoopeston Regional Hlth Center,8980250,"water for injection, bacteriostatic injection solution",409397703,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,aminocaproic acid 250 mg/mL intravenous solution,409434673,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,pancuronium 1 mg/mL intravenous solution,409464601,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,sodium bicarbonate 10 mEq/10 mL (8.4 %) intravenous syringe,409490034,,250,$101.53 ,$101.53 ,$28.43 ,$92.90 ,$71.07 ,$84.98 ,$92.90 ,$92.90 ,$92.90 ,$37.41 ,$60.92 ,$30.46 ,$91.38 ,$76.15 ,$81.22 ,$84.27
Hoopeston Regional Hlth Center,8980250,calcium chloride 100 mg/mL (10 %) intravenous syringe,409492834,,250,$70.80 ,$70.80 ,$19.82 ,$64.78 ,$49.56 ,$59.26 ,$64.78 ,$64.78 ,$64.78 ,$26.09 ,$42.48 ,$21.24 ,$63.72 ,$53.10 ,$56.64 ,$58.76
Hoopeston Regional Hlth Center,8980250,sodium bicarbonate 4.2 % (0.5 mEq/mL) intravenous syringe,409553434,,250,$78.89 ,$78.89 ,$22.09 ,$72.18 ,$55.22 ,$66.03 ,$72.18 ,$72.18 ,$72.18 ,$29.07 ,$47.33 ,$23.67 ,$71.00 ,$59.17 ,$63.11 ,$65.48
Hoopeston Regional Hlth Center,8980250,"water for irrigation, sterile solution",409613903,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,"water for irrigation, sterile solution",409613922,,250,$162.97 ,$162.97 ,$45.63 ,$149.12 ,$114.08 ,$136.41 ,$149.12 ,$149.12 ,$149.12 ,$60.05 ,$97.78 ,$48.89 ,$146.67 ,$122.23 ,$130.38 ,$135.27
Hoopeston Regional Hlth Center,8980250,sodium bicarbonate 1 mEq/mL (8.4 %) intravenous solution,409662502,,250,$103.04 ,$103.04 ,$28.85 ,$94.28 ,$72.13 ,$86.24 ,$94.28 ,$94.28 ,$94.28 ,$37.97 ,$61.82 ,$30.91 ,$92.74 ,$77.28 ,$82.43 ,$85.52
Hoopeston Regional Hlth Center,8980250,sodium bicarbonate 8.4 % (1 mEq/mL) intravenous syringe,409663734,,250,$79.06 ,$79.06 ,$22.14 ,$72.34 ,$55.34 ,$66.17 ,$72.34 ,$72.34 ,$72.34 ,$29.13 ,$47.44 ,$23.72 ,$71.15 ,$59.30 ,$63.25 ,$65.62
Hoopeston Regional Hlth Center,8980250,"dextrose 50 % in water (D50W) intravenous syringe,dextrose 50 % in water (D50W) intravenous solution",409664802,J3490,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,"water for injection, sterile intravenous solution",409711807,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,hetastarch 6 % in 0.9 % sodium chloride intravenous solution,409724803,,250,$116.41 ,$116.41 ,$32.59 ,$106.52 ,$81.49 ,$97.44 ,$106.52 ,$106.52 ,$106.52 ,$42.90 ,$69.85 ,$34.92 ,$104.77 ,$87.31 ,$93.13 ,$96.62
Hoopeston Regional Hlth Center,8980250,potassium phosphates-mbasic and dibasic 3 mmol/mL intravenous solution,409729501,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,sodium phosphate 3 mmol/mL intravenous solution,409739172,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,"dextrose 50 % in water (D50W) intravenous syringe,dextrose 50 % in water (D50W) intravenous solution",409751716,J3490,250,$67.71 ,$67.71 ,$18.96 ,$61.95 ,$47.40 ,$56.67 ,$61.95 ,$61.95 ,$61.95 ,$24.95 ,$40.63 ,$20.31 ,$60.94 ,$50.78 ,$54.17 ,$56.20
Hoopeston Regional Hlth Center,8980250,electrolyte-M in 5 % dextrose intravenous solution,409796509,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,electrolyte-R intravenous solution,409796709,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,"water for irrigation, sterile solution",409797305,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,"water for irrigation, sterile solution",409797308,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,glycine 1.5 % urologic solution for irrigation,409797408,,250,$98.95 ,$98.95 ,$27.71 ,$90.54 ,$69.27 ,$82.82 ,$90.54 ,$90.54 ,$90.54 ,$36.46 ,$59.37 ,$29.69 ,$89.06 ,$74.21 ,$79.16 ,$82.13
Hoopeston Regional Hlth Center,8980250,Ringer's intravenous solution,409798209,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,"water for injection, sterile intravenous solution",409799009,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,potassium acetate 2 mEq/mL intravenous solution,409818301,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,"bupivacaine-epinephrine (PF) 0.25 %-1:200,000 injection solution",409904201,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,thyroid (pork) 60 mg tablet,456045901,,250,$7.50 ,$7.50 ,$2.10 ,$6.86 ,$5.25 ,$6.28 ,$6.86 ,$6.86 ,$6.86 ,$2.76 ,$4.50 ,$2.25 ,$6.75 ,$5.63 ,$6.00 ,$6.23
Hoopeston Regional Hlth Center,8980250,asenapine 5 mg sublingual tablet,456240560,,250,$92.21 ,$92.21 ,$25.82 ,$84.37 ,$64.55 ,$77.18 ,$84.37 ,$84.37 ,$84.37 ,$33.98 ,$55.33 ,$27.66 ,$82.99 ,$69.16 ,$73.77 ,$76.53
Hoopeston Regional Hlth Center,8980250,griseofulvin microsize 125 mg/5 mL oral suspension,472001304,,250,$25.91 ,$25.91 ,$7.25 ,$23.71 ,$18.14 ,$21.69 ,$23.71 ,$23.71 ,$23.71 ,$9.55 ,$15.55 ,$7.77 ,$23.32 ,$19.43 ,$20.73 ,$21.51
Hoopeston Regional Hlth Center,8980250,acyclovir 200 mg/5 mL oral suspension,472008216,,250,$12.39 ,$12.39 ,$3.47 ,$11.34 ,$8.67 ,$10.37 ,$11.34 ,$11.34 ,$11.34 ,$4.57 ,$7.43 ,$3.72 ,$11.15 ,$9.29 ,$9.91 ,$10.28
Hoopeston Regional Hlth Center,8980250,miconazole nitrate 2 % topical cream,472073556,,250,$21.43 ,$21.43 ,$6.00 ,$19.61 ,$15.00 ,$17.94 ,$19.61 ,$19.61 ,$19.61 ,$7.90 ,$12.86 ,$6.43 ,$19.29 ,$16.07 ,$17.14 ,$17.79
Hoopeston Regional Hlth Center,8980250,ipratropium 0.5 mg-albuteroL 3 mg (2.5 mg base)/3 mL nebulization soln,487020101,,250,$5.13 ,$5.13 ,$1.44 ,$4.69 ,$3.59 ,$4.29 ,$4.69 ,$4.69 ,$4.69 ,$1.89 ,$3.08 ,$1.54 ,$4.62 ,$3.85 ,$4.10 ,$4.26
Hoopeston Regional Hlth Center,8980250,lidocaine 4 % topical cream,496088206,,250,$52.39 ,$52.39 ,$14.67 ,$47.94 ,$36.67 ,$43.85 ,$47.94 ,$47.94 ,$47.94 ,$19.31 ,$31.43 ,$15.72 ,$47.15 ,$39.29 ,$41.91 ,$43.48
Hoopeston Regional Hlth Center,8980250,indigotindisulfonate sodium 8 mg/mL (0.8 %) injection solution,517037505,,250,"$1,090.98 ","$1,090.98 ",$305.47 ,$998.25 ,$763.69 ,$913.15 ,$998.25 ,$998.25 ,$998.25 ,$402.03 ,$654.59 ,$327.29 ,$981.88 ,$818.24 ,$872.78 ,$905.51
Hoopeston Regional Hlth Center,8980250,glycopyrrolate 0.2 mg/mL injection solution,517460525,J3490,250,$323.50 ,$323.50 ,$90.58 ,$296.00 ,$226.45 ,$270.77 ,$296.00 ,$296.00 ,$296.00 ,$119.21 ,$194.10 ,$97.05 ,$291.15 ,$242.63 ,$258.80 ,$268.51
Hoopeston Regional Hlth Center,8980250,nitroglycerin 50 mg/10 mL (5 mg/mL) intravenous solution,517481025,,250,$134.59 ,$134.59 ,$37.69 ,$123.15 ,$94.21 ,$112.65 ,$123.15 ,$123.15 ,$123.15 ,$49.60 ,$80.75 ,$40.38 ,$121.13 ,$100.94 ,$107.67 ,$111.71
Hoopeston Regional Hlth Center,8980250,zinc sulfate 5 mg/mL intravenous solution,517800525,,250,$132.90 ,$132.90 ,$37.21 ,$121.60 ,$93.03 ,$111.24 ,$121.60 ,$121.60 ,$121.60 ,$48.97 ,$79.74 ,$39.87 ,$119.61 ,$99.68 ,$106.32 ,$110.31
Hoopeston Regional Hlth Center,8980250,primidone 50 mg tablet,527130101,,250,$4.67 ,$4.67 ,$1.31 ,$4.27 ,$3.27 ,$3.91 ,$4.27 ,$4.27 ,$4.27 ,$1.72 ,$2.80 ,$1.40 ,$4.20 ,$3.50 ,$3.74 ,$3.88
Hoopeston Regional Hlth Center,8980250,pilocarpine 5 mg tablet,527131301,,250,$10.78 ,$10.78 ,$3.02 ,$9.86 ,$7.55 ,$9.02 ,$9.86 ,$9.86 ,$9.86 ,$3.97 ,$6.47 ,$3.23 ,$9.70 ,$8.09 ,$8.62 ,$8.95
Hoopeston Regional Hlth Center,8980250,terbutaline 2.5 mg tablet,527131801,,250,$27.20 ,$27.20 ,$7.62 ,$24.89 ,$19.04 ,$22.77 ,$24.89 ,$24.89 ,$24.89 ,$10.02 ,$16.32 ,$8.16 ,$24.48 ,$20.40 ,$21.76 ,$22.58
Hoopeston Regional Hlth Center,8980250,levothyroxine 88 mcg tablet,527134401,,250,$4.93 ,$4.93 ,$1.38 ,$4.51 ,$3.45 ,$4.13 ,$4.51 ,$4.51 ,$4.51 ,$1.82 ,$2.96 ,$1.48 ,$4.44 ,$3.70 ,$3.94 ,$4.09
Hoopeston Regional Hlth Center,8980250,levothyroxine 150 mcg tablet,527134901,,250,$5.49 ,$5.49 ,$1.54 ,$5.02 ,$3.84 ,$4.60 ,$5.02 ,$5.02 ,$5.02 ,$2.02 ,$3.29 ,$1.65 ,$4.94 ,$4.12 ,$4.39 ,$4.56
Hoopeston Regional Hlth Center,8980250,lidocaine HCL 4 % (40 mg/mL) mucosal solution,527600480,,250,$322.24 ,$322.24 ,$90.23 ,$294.85 ,$225.57 ,$269.71 ,$294.85 ,$294.85 ,$294.85 ,$118.75 ,$193.34 ,$96.67 ,$290.02 ,$241.68 ,$257.79 ,$267.46
Hoopeston Regional Hlth Center,8980250,"simethicone 40 mg/0.6 mL oral drops,suspension",536222075,,250,$44.53 ,$44.53 ,$12.47 ,$40.74 ,$31.17 ,$37.27 ,$40.74 ,$40.74 ,$40.74 ,$16.41 ,$26.72 ,$13.36 ,$40.08 ,$33.40 ,$35.62 ,$36.96
Hoopeston Regional Hlth Center,8980250,nicotine 7 mg/24 hr daily transdermal patch,536589488,,250,$3.00 ,$3.00 ,$0.84 ,$2.75 ,$2.10 ,$2.51 ,$2.75 ,$2.75 ,$2.75 ,$1.11 ,$1.80 ,$0.90 ,$2.70 ,$2.25 ,$2.40 ,$2.49
Hoopeston Regional Hlth Center,8980250,nicotine 14 mg/24 hr daily transdermal patch,536589588,,250,$3.00 ,$3.00 ,$0.84 ,$2.75 ,$2.10 ,$2.51 ,$2.75 ,$2.75 ,$2.75 ,$1.11 ,$1.80 ,$0.90 ,$2.70 ,$2.25 ,$2.40 ,$2.49
Hoopeston Regional Hlth Center,8980250,nicotine 21 mg/24 hr daily transdermal patch,536589688,,250,$3.00 ,$3.00 ,$0.84 ,$2.75 ,$2.10 ,$2.51 ,$2.75 ,$2.75 ,$2.75 ,$1.11 ,$1.80 ,$0.90 ,$2.70 ,$2.25 ,$2.40 ,$2.49
Hoopeston Regional Hlth Center,8980250,mefloquine 250 mg tablet,555017178,,250,$45.22 ,$45.22 ,$12.66 ,$41.38 ,$31.65 ,$37.85 ,$41.38 ,$41.38 ,$41.38 ,$16.66 ,$27.13 ,$13.57 ,$40.70 ,$33.92 ,$36.18 ,$37.53
Hoopeston Regional Hlth Center,8980250,medroxyPROGESTERone 2.5 mg tablet,555087202,,250,$3.79 ,$3.79 ,$1.06 ,$3.47 ,$2.65 ,$3.17 ,$3.47 ,$3.47 ,$3.47 ,$1.40 ,$2.27 ,$1.14 ,$3.41 ,$2.84 ,$3.03 ,$3.15
Hoopeston Regional Hlth Center,8980250,dextrose 40 % oral gel,574006930,J3490,250,$5.51 ,$5.51 ,$1.54 ,$5.04 ,$3.86 ,$4.61 ,$5.04 ,$5.04 ,$5.04 ,$2.03 ,$3.31 ,$1.65 ,$4.96 ,$4.13 ,$4.41 ,$4.57
Hoopeston Regional Hlth Center,8980250,clotrimazole 10 mg troche,574010777,,250,$8.99 ,$8.99 ,$2.52 ,$8.23 ,$6.29 ,$7.52 ,$8.23 ,$8.23 ,$8.23 ,$3.31 ,$5.39 ,$2.70 ,$8.09 ,$6.74 ,$7.19 ,$7.46
Hoopeston Regional Hlth Center,8980250,activated charcoal-sorbitoL 50 gram/240 mL oral suspension,574012076,,250,$113.05 ,$113.05 ,$31.65 ,$103.44 ,$79.14 ,$94.62 ,$103.44 ,$103.44 ,$103.44 ,$41.66 ,$67.83 ,$33.92 ,$101.75 ,$84.79 ,$90.44 ,$93.83
Hoopeston Regional Hlth Center,8980250,activated charcoaL 50 gram/240 mL oral suspension,574012176,,250,$113.05 ,$113.05 ,$31.65 ,$103.44 ,$79.14 ,$94.62 ,$103.44 ,$103.44 ,$103.44 ,$41.66 ,$67.83 ,$33.92 ,$101.75 ,$84.79 ,$90.44 ,$93.83
Hoopeston Regional Hlth Center,8980250,compounding vehicle suspension sugar-free no.20 oral,574030316,,250,$133.62 ,$133.62 ,$37.41 ,$122.26 ,$93.53 ,$111.84 ,$122.26 ,$122.26 ,$122.26 ,$49.24 ,$80.17 ,$40.09 ,$120.26 ,$100.22 ,$106.90 ,$110.90
Hoopeston Regional Hlth Center,8980250,"ferrous sulfate 324 mg (65 mg iron) tablet,delayed release",574060810,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,"nystatin 100,000 unit/gram topical powder",574200815,,250,$148.96 ,$148.96 ,$41.71 ,$136.30 ,$104.27 ,$124.68 ,$136.30 ,$136.30 ,$136.30 ,$54.89 ,$89.38 ,$44.69 ,$134.06 ,$111.72 ,$119.17 ,$123.64
Hoopeston Regional Hlth Center,8980250,"bacitracin-polymyxin B 500 unit-10,000 unit/gram eye ointment",574402135,,250,$127.47 ,$127.47 ,$35.69 ,$116.64 ,$89.23 ,$106.69 ,$116.64 ,$116.64 ,$116.64 ,$46.97 ,$76.48 ,$38.24 ,$114.72 ,$95.60 ,$101.98 ,$105.80
Hoopeston Regional Hlth Center,8980250,aspirin 300 mg rectal suppository,574703412,,250,$2.04 ,$2.04 ,$0.57 ,$1.87 ,$1.43 ,$1.71 ,$1.87 ,$1.87 ,$1.87 ,$0.75 ,$1.22 ,$0.61 ,$1.84 ,$1.53 ,$1.63 ,$1.69
Hoopeston Regional Hlth Center,8980250,bisacodyL 10 mg rectal suppository,574705050,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,prochlorperazine 25 mg rectal suppository,574722612,,250,$52.19 ,$52.19 ,$14.61 ,$47.75 ,$36.53 ,$43.68 ,$47.75 ,$47.75 ,$47.75 ,$19.23 ,$31.31 ,$15.66 ,$46.97 ,$39.14 ,$41.75 ,$43.32
Hoopeston Regional Hlth Center,8980250,glipiZIDE 5 mg tablet,591046005,,250,$4.00 ,$4.00 ,$1.12 ,$3.66 ,$2.80 ,$3.35 ,$3.66 ,$3.66 ,$3.66 ,$1.47 ,$2.40 ,$1.20 ,$3.60 ,$3.00 ,$3.20 ,$3.32
Hoopeston Regional Hlth Center,8980250,propafenone 150 mg tablet,591058201,,250,$9.95 ,$9.95 ,$2.79 ,$9.10 ,$6.97 ,$8.33 ,$9.10 ,$9.10 ,$9.10 ,$3.67 ,$5.97 ,$2.99 ,$8.96 ,$7.46 ,$7.96 ,$8.26
Hoopeston Regional Hlth Center,8980250,labetaloL 100 mg tablet,591060501,,250,$4.67 ,$4.67 ,$1.31 ,$4.27 ,$3.27 ,$3.91 ,$4.27 ,$4.27 ,$4.27 ,$1.72 ,$2.80 ,$1.40 ,$4.20 ,$3.50 ,$3.74 ,$3.88
Hoopeston Regional Hlth Center,8980250,labetaloL 200 mg tablet,591060601,,250,$5.65 ,$5.65 ,$1.58 ,$5.17 ,$3.96 ,$4.73 ,$5.17 ,$5.17 ,$5.17 ,$2.08 ,$3.39 ,$1.70 ,$5.09 ,$4.24 ,$4.52 ,$4.69
Hoopeston Regional Hlth Center,8980250,sulfaSALAzine 500 mg tablet,591079601,,250,$3.52 ,$3.52 ,$0.99 ,$3.22 ,$2.46 ,$2.95 ,$3.22 ,$3.22 ,$3.22 ,$1.30 ,$2.11 ,$1.06 ,$3.17 ,$2.64 ,$2.82 ,$2.92
Hoopeston Regional Hlth Center,8980250,"verapamiL ER 180 mg 24 hr capsule,extended release",591288201,,250,$10.85 ,$10.85 ,$3.04 ,$9.93 ,$7.60 ,$9.08 ,$9.93 ,$9.93 ,$9.93 ,$4.00 ,$6.51 ,$3.26 ,$9.77 ,$8.14 ,$8.68 ,$9.01
Hoopeston Regional Hlth Center,8980250,"verapamiL ER 240 mg 24 hr capsule,extended release",591288401,,250,$11.95 ,$11.95 ,$3.35 ,$10.93 ,$8.37 ,$10.00 ,$10.93 ,$10.93 ,$10.93 ,$4.40 ,$7.17 ,$3.59 ,$10.76 ,$8.96 ,$9.56 ,$9.92
Hoopeston Regional Hlth Center,8980250,promethazine 25 mg rectal suppository,591299239,,250,$70.12 ,$70.12 ,$19.63 ,$64.16 ,$49.08 ,$58.69 ,$64.16 ,$64.16 ,$64.16 ,$25.84 ,$42.07 ,$21.04 ,$63.11 ,$52.59 ,$56.10 ,$58.20
Hoopeston Regional Hlth Center,8980250,ursodioL 300 mg capsule,591315901,,250,$33.88 ,$33.88 ,$9.49 ,$31.00 ,$23.72 ,$28.36 ,$31.00 ,$31.00 ,$31.00 ,$12.48 ,$20.33 ,$10.16 ,$30.49 ,$25.41 ,$27.10 ,$28.12
Hoopeston Regional Hlth Center,8980250,nabumetone 500 mg tablet,591367001,,250,$8.37 ,$8.37 ,$2.34 ,$7.66 ,$5.86 ,$7.01 ,$7.66 ,$7.66 ,$7.66 ,$3.08 ,$5.02 ,$2.51 ,$7.53 ,$6.28 ,$6.70 ,$6.95
Hoopeston Regional Hlth Center,8980250,tranexamic acid 650 mg tablet,591372030,,250,$44.69 ,$44.69 ,$12.51 ,$40.89 ,$31.28 ,$37.41 ,$40.89 ,$40.89 ,$40.89 ,$16.47 ,$26.81 ,$13.41 ,$40.22 ,$33.52 ,$35.75 ,$37.09
Hoopeston Regional Hlth Center,8980250,primidone 250 mg tablet,591532101,,250,$6.97 ,$6.97 ,$1.95 ,$6.38 ,$4.88 ,$5.83 ,$6.38 ,$6.38 ,$6.38 ,$2.57 ,$4.18 ,$2.09 ,$6.27 ,$5.23 ,$5.58 ,$5.79
Hoopeston Regional Hlth Center,8980250,trihexyphenidyL 2 mg tablet,591533501,,250,$3.18 ,$3.18 ,$0.89 ,$2.91 ,$2.23 ,$2.66 ,$2.91 ,$2.91 ,$2.91 ,$1.17 ,$1.91 ,$0.95 ,$2.86 ,$2.39 ,$2.54 ,$2.64
Hoopeston Regional Hlth Center,8980250,probenecid 500 mg tablet,591534701,,250,$6.91 ,$6.91 ,$1.93 ,$6.32 ,$4.84 ,$5.78 ,$6.32 ,$6.32 ,$6.32 ,$2.55 ,$4.15 ,$2.07 ,$6.22 ,$5.18 ,$5.53 ,$5.74
Hoopeston Regional Hlth Center,8980250,allopurinoL 300 mg tablet,591554401,,250,$6.64 ,$6.64 ,$1.86 ,$6.08 ,$4.65 ,$5.56 ,$6.08 ,$6.08 ,$6.08 ,$2.45 ,$3.98 ,$1.99 ,$5.98 ,$4.98 ,$5.31 ,$5.51
Hoopeston Regional Hlth Center,8980250,propranoloL 20 mg tablet,591555501,,250,$4.71 ,$4.71 ,$1.32 ,$4.31 ,$3.30 ,$3.94 ,$4.31 ,$4.31 ,$4.31 ,$1.74 ,$2.83 ,$1.41 ,$4.24 ,$3.53 ,$3.77 ,$3.91
Hoopeston Regional Hlth Center,8980250,propranoloL 40 mg tablet,591555601,,250,$5.67 ,$5.67 ,$1.59 ,$5.19 ,$3.97 ,$4.75 ,$5.19 ,$5.19 ,$5.19 ,$2.09 ,$3.40 ,$1.70 ,$5.10 ,$4.25 ,$4.54 ,$4.71
Hoopeston Regional Hlth Center,8980250,minoxidiL 10 mg tablet,591564301,,250,$8.35 ,$8.35 ,$2.34 ,$7.64 ,$5.85 ,$6.99 ,$7.64 ,$7.64 ,$7.64 ,$3.08 ,$5.01 ,$2.51 ,$7.52 ,$6.26 ,$6.68 ,$6.93
Hoopeston Regional Hlth Center,8980250,cyclobenzaprine 10 mg tablet,591565805,,250,$7.52 ,$7.52 ,$2.11 ,$6.88 ,$5.26 ,$6.29 ,$6.88 ,$6.88 ,$6.88 ,$2.77 ,$4.51 ,$2.26 ,$6.77 ,$5.64 ,$6.02 ,$6.24
Hoopeston Regional Hlth Center,8980250,ipratropium 20 mcg-albuteroL 100 mcg/actuation mist for inhalation,597002402,,250,"$2,501.08 ","$2,501.08 ",$700.30 ,"$2,288.49 ","$1,750.76 ","$2,093.40 ","$2,288.49 ","$2,288.49 ","$2,288.49 ",$921.65 ,"$1,500.65 ",$750.32 ,"$2,250.97 ","$1,875.81 ","$2,000.86 ","$2,075.90 "
Hoopeston Regional Hlth Center,8980250,nevirapine 50 mg/5 mL oral suspension,597004724,,250,$121.18 ,$121.18 ,$33.93 ,$110.88 ,$84.83 ,$101.43 ,$110.88 ,$110.88 ,$110.88 ,$44.65 ,$72.71 ,$36.35 ,$109.06 ,$90.89 ,$96.94 ,$100.58
Hoopeston Regional Hlth Center,8980250,tiotropium bromide 18 mcg capsule with inhalation device,597007575,,250,$634.23 ,$634.23 ,$177.58 ,$580.32 ,$443.96 ,$530.85 ,$580.32 ,$580.32 ,$580.32 ,$233.71 ,$380.54 ,$190.27 ,$570.81 ,$475.67 ,$507.38 ,$526.41
Hoopeston Regional Hlth Center,8980250,ipratropium bromide 17 mcg/actuation HFA aerosol inhaler,597008717,,250,"$2,413.51 ","$2,413.51 ",$675.78 ,"$2,208.36 ","$1,689.46 ","$2,020.11 ","$2,208.36 ","$2,208.36 ","$2,208.36 ",$889.38 ,"$1,448.11 ",$724.05 ,"$2,172.16 ","$1,810.13 ","$1,930.81 ","$2,003.21 "
Hoopeston Regional Hlth Center,8980250,tiotropium bromide 2.5 mcg/actuation mist for inhalation,597010051,,250,$440.37 ,$440.37 ,$123.30 ,$402.94 ,$308.26 ,$368.59 ,$402.94 ,$402.94 ,$402.94 ,$162.28 ,$264.22 ,$132.11 ,$396.33 ,$330.28 ,$352.30 ,$365.51
Hoopeston Regional Hlth Center,8980250,tiotropium 2.5 mcg-olodateroL 2.5 mcg/actuation mist for inhalation,597015570,,250,$440.37 ,$440.37 ,$123.30 ,$402.94 ,$308.26 ,$368.59 ,$402.94 ,$402.94 ,$402.94 ,$162.28 ,$264.22 ,$132.11 ,$396.33 ,$330.28 ,$352.30 ,$365.51
Hoopeston Regional Hlth Center,8980250,idaruCIZUmab 2.5 gram/50 mL intravenous solution,597019705,,250,"$12,002.11 ","$12,002.11 ","$3,360.59 ","$10,981.93 ","$8,401.48 ","$10,045.77 ","$10,981.93 ","$10,981.93 ","$10,981.93 ","$4,422.78 ","$7,201.27 ","$3,600.63 ","$10,801.90 ","$9,001.58 ","$9,601.69 ","$9,961.75 "
Hoopeston Regional Hlth Center,8980250,dabigatran etexilate 75 mg capsule,597035556,,250,$41.53 ,$41.53 ,$11.63 ,$38.00 ,$29.07 ,$34.76 ,$38.00 ,$38.00 ,$38.00 ,$15.30 ,$24.92 ,$12.46 ,$37.38 ,$31.15 ,$33.22 ,$34.47
Hoopeston Regional Hlth Center,8980250,dabigatran etexilate 150 mg capsule,597036082,,250,$41.53 ,$41.53 ,$11.63 ,$38.00 ,$29.07 ,$34.76 ,$38.00 ,$38.00 ,$38.00 ,$15.30 ,$24.92 ,$12.46 ,$37.38 ,$31.15 ,$33.22 ,$34.47
Hoopeston Regional Hlth Center,8980250,dicyclomine 10 mg/5 mL oral solution,603116158,,250,$15.60 ,$15.60 ,$4.37 ,$14.27 ,$10.92 ,$13.06 ,$14.27 ,$14.27 ,$14.27 ,$5.75 ,$9.36 ,$4.68 ,$14.04 ,$11.70 ,$12.48 ,$12.95
Hoopeston Regional Hlth Center,8980250,potassium bicarbonate and chloride 25 mEq effervescent tablet,603350816,,250,$8.99 ,$8.99 ,$2.52 ,$8.23 ,$6.29 ,$7.52 ,$8.23 ,$8.23 ,$8.23 ,$3.31 ,$5.39 ,$2.70 ,$8.09 ,$6.74 ,$7.19 ,$7.46
Hoopeston Regional Hlth Center,8980250,oxyCODONE-acetaminophen 5 mg-325 mg tablet,603499828,,250,$9.49 ,$9.49 ,$2.66 ,$8.68 ,$6.64 ,$7.94 ,$8.68 ,$8.68 ,$8.68 ,$3.50 ,$5.69 ,$2.85 ,$8.54 ,$7.12 ,$7.59 ,$7.88
Hoopeston Regional Hlth Center,8980250,digoxin 250 mcg/mL (0.25 mg/mL) injection solution,641141035,J1160,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,bumetanide 0.25 mg/mL injection solution,641600701,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,bumetanide 0.25 mg/mL injection solution,641600710,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,bumetanide 0.25 mg/mL injection solution,641600801,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,bumetanide 0.25 mg/mL injection solution,641600810,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,morphine (PF) 25 mg/mL injection solution,641604001,,250,"$2,522.31 ","$2,522.31 ",$706.25 ,"$2,307.91 ","$1,765.62 ","$2,111.17 ","$2,307.91 ","$2,307.91 ","$2,307.91 ",$929.47 ,"$1,513.39 ",$756.69 ,"$2,270.08 ","$1,891.73 ","$2,017.85 ","$2,093.52 "
Hoopeston Regional Hlth Center,8980250,rocuronium 10 mg/mL intravenous solution,703239403,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,rocuronium 10 mg/mL intravenous solution,703239503,,250,$55.20 ,$55.20 ,$15.46 ,$50.51 ,$38.64 ,$46.20 ,$50.51 ,$50.51 ,$50.51 ,$20.34 ,$33.12 ,$16.56 ,$49.68 ,$41.40 ,$44.16 ,$45.82
Hoopeston Regional Hlth Center,8980250,"bacitracin 500 unit/gram topical ointment,bacitracin zinc 500 unit/gram topical ointment",713028031,J3490,250,$22.72 ,$22.72 ,$6.36 ,$20.79 ,$15.90 ,$19.02 ,$20.79 ,$20.79 ,$20.79 ,$8.37 ,$13.63 ,$6.82 ,$20.45 ,$17.04 ,$18.18 ,$18.86
Hoopeston Regional Hlth Center,8980250,promethazine 12.5 mg rectal suppository,713053612,,250,$70.12 ,$70.12 ,$19.63 ,$64.16 ,$49.08 ,$58.69 ,$64.16 ,$64.16 ,$64.16 ,$25.84 ,$42.07 ,$21.04 ,$63.11 ,$52.59 ,$56.10 ,$58.20
Hoopeston Regional Hlth Center,8980250,haloperidoL 5 mg tablet,781139613,,250,$6.87 ,$6.87 ,$1.92 ,$6.29 ,$4.81 ,$5.75 ,$6.29 ,$6.29 ,$6.29 ,$2.53 ,$4.12 ,$2.06 ,$6.18 ,$5.15 ,$5.50 ,$5.70
Hoopeston Regional Hlth Center,8980250,isosorbide dinitrate 10 mg tablet,781155601,,250,$7.38 ,$7.38 ,$2.07 ,$6.75 ,$5.17 ,$6.18 ,$6.75 ,$6.75 ,$6.75 ,$2.72 ,$4.43 ,$2.21 ,$6.64 ,$5.54 ,$5.90 ,$6.13
Hoopeston Regional Hlth Center,8980250,imipramine 50 mg tablet,781176613,,250,$9.15 ,$9.15 ,$2.56 ,$8.37 ,$6.41 ,$7.66 ,$8.37 ,$8.37 ,$8.37 ,$3.37 ,$5.49 ,$2.75 ,$8.24 ,$6.86 ,$7.32 ,$7.59
Hoopeston Regional Hlth Center,8980250,clarithromycin 250 mg tablet,781196160,,250,$29.20 ,$29.20 ,$8.18 ,$26.72 ,$20.44 ,$24.44 ,$26.72 ,$26.72 ,$26.72 ,$10.76 ,$17.52 ,$8.76 ,$26.28 ,$21.90 ,$23.36 ,$24.24
Hoopeston Regional Hlth Center,8980250,clarithromycin 500 mg tablet,781196260,,250,$29.20 ,$29.20 ,$8.18 ,$26.72 ,$20.44 ,$24.44 ,$26.72 ,$26.72 ,$26.72 ,$10.76 ,$17.52 ,$8.76 ,$26.28 ,$21.90 ,$23.36 ,$24.24
Hoopeston Regional Hlth Center,8980250,triamterene 37.5 mg-hydrochlorothiazide 25 mg capsule,781207401,,250,$4.08 ,$4.08 ,$1.14 ,$3.73 ,$2.86 ,$3.41 ,$3.73 ,$3.73 ,$3.73 ,$1.50 ,$2.45 ,$1.22 ,$3.67 ,$3.06 ,$3.26 ,$3.39
Hoopeston Regional Hlth Center,8980250,amoxicillin 500 mg capsule,781261301,,250,$4.35 ,$4.35 ,$1.22 ,$3.98 ,$3.05 ,$3.64 ,$3.98 ,$3.98 ,$3.98 ,$1.60 ,$2.61 ,$1.31 ,$3.92 ,$3.26 ,$3.48 ,$3.61
Hoopeston Regional Hlth Center,8980250,clindamycin 600 mg/50 mL in 5 % dextrose intravenous piggyback,781328909,,250,$89.83 ,$89.83 ,$25.15 ,$82.19 ,$62.88 ,$75.19 ,$82.19 ,$82.19 ,$82.19 ,$33.10 ,$53.90 ,$26.95 ,$80.85 ,$67.37 ,$71.86 ,$74.56
Hoopeston Regional Hlth Center,8980250,clindamycin 900 mg/50 mL in 5 % dextrose intravenous piggyback,781329009,,250,$108.74 ,$108.74 ,$30.45 ,$99.50 ,$76.12 ,$91.02 ,$99.50 ,$99.50 ,$99.50 ,$40.07 ,$65.24 ,$32.62 ,$97.87 ,$81.56 ,$86.99 ,$90.25
Hoopeston Regional Hlth Center,8980250,amoxicillin 400 mg/5 mL oral suspension,781615746,,250,$9.84 ,$9.84 ,$2.76 ,$9.00 ,$6.89 ,$8.24 ,$9.00 ,$9.00 ,$9.00 ,$3.63 ,$5.90 ,$2.95 ,$8.86 ,$7.38 ,$7.87 ,$8.17
Hoopeston Regional Hlth Center,8980250,albuterol sulfate HFA 90 mcg/actuation aerosol inhaler,781729685,,250,$230.56 ,$230.56 ,$64.56 ,$210.96 ,$161.39 ,$192.98 ,$210.96 ,$210.96 ,$210.96 ,$84.96 ,$138.34 ,$69.17 ,$207.50 ,$172.92 ,$184.45 ,$191.36
Hoopeston Regional Hlth Center,8980250,rivastigmine 9.5 mg/24 hour transdermal patch,781730931,,250,$67.29 ,$67.29 ,$18.84 ,$61.57 ,$47.10 ,$56.32 ,$61.57 ,$61.57 ,$61.57 ,$24.80 ,$40.37 ,$20.19 ,$60.56 ,$50.47 ,$53.83 ,$55.85
Hoopeston Regional Hlth Center,8980250,eplerenone 25 mg tablet,832048030,,250,$22.55 ,$22.55 ,$6.31 ,$20.63 ,$15.79 ,$18.87 ,$20.63 ,$20.63 ,$20.63 ,$8.31 ,$13.53 ,$6.77 ,$20.30 ,$16.91 ,$18.04 ,$18.72
Hoopeston Regional Hlth Center,8980250,cloBAZam 10 mg tablet,832058011,,250,$74.56 ,$74.56 ,$20.88 ,$68.22 ,$52.19 ,$62.41 ,$68.22 ,$68.22 ,$68.22 ,$27.48 ,$44.74 ,$22.37 ,$67.10 ,$55.92 ,$59.65 ,$61.88
Hoopeston Regional Hlth Center,8980250,amantadine HCL 100 mg capsule,832101500,,250,$11.74 ,$11.74 ,$3.29 ,$10.74 ,$8.22 ,$9.83 ,$10.74 ,$10.74 ,$10.74 ,$4.33 ,$7.04 ,$3.52 ,$10.57 ,$8.81 ,$9.39 ,$9.74
Hoopeston Regional Hlth Center,8980250,baclofen 10 mg tablet,832105415,,250,$12.87 ,$12.87 ,$3.60 ,$11.78 ,$9.01 ,$10.77 ,$11.78 ,$11.78 ,$11.78 ,$4.74 ,$7.72 ,$3.86 ,$11.58 ,$9.65 ,$10.30 ,$10.68
Hoopeston Regional Hlth Center,8980250,baclofen 20 mg tablet,832105515,,250,$26.04 ,$26.04 ,$7.29 ,$23.83 ,$18.23 ,$21.80 ,$23.83 ,$23.83 ,$23.83 ,$9.60 ,$15.62 ,$7.81 ,$23.44 ,$19.53 ,$20.83 ,$21.61
Hoopeston Regional Hlth Center,8980250,magnesium citrate oral solution,869016638,,250,$1.66 ,$1.66 ,$0.46 ,$1.52 ,$1.16 ,$1.39 ,$1.52 ,$1.52 ,$1.52 ,$0.61 ,$1.00 ,$0.50 ,$1.49 ,$1.25 ,$1.33 ,$1.38
Hoopeston Regional Hlth Center,8980250,aluminum-mag hydroxide-simethicone 200 mg-200 mg-20 mg/5 mL oral susp,904000414,J3490,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,"vitamin E (dl, acetate) 90 mg (200 unit) capsule",904027260,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,ascorbic acid (vitamin C) 500 mg tablet,904052380,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,"vitamin A 10,000 unit capsule",904208560,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,verapamiL 80 mg tablet,904292061,,250,$4.99 ,$4.99 ,$1.40 ,$4.57 ,$3.49 ,$4.18 ,$4.57 ,$4.57 ,$4.57 ,$1.84 ,$2.99 ,$1.50 ,$4.49 ,$3.74 ,$3.99 ,$4.14
Hoopeston Regional Hlth Center,8980250,verapamiL 120 mg tablet,904292461,,250,$5.83 ,$5.83 ,$1.63 ,$5.33 ,$4.08 ,$4.88 ,$5.33 ,$5.33 ,$5.33 ,$2.15 ,$3.50 ,$1.75 ,$5.25 ,$4.37 ,$4.66 ,$4.84
Hoopeston Regional Hlth Center,8980250,aspirin 81 mg chewable tablet,904404073,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,simethicone 80 mg chewable tablet,904506860,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,pseudoephedrine 60 mg tablet,904512559,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,rifAMPin 300 mg capsule,904528261,,250,$8.51 ,$8.51 ,$2.38 ,$7.79 ,$5.96 ,$7.12 ,$7.79 ,$7.79 ,$7.79 ,$3.14 ,$5.11 ,$2.55 ,$7.66 ,$6.38 ,$6.81 ,$7.06
Hoopeston Regional Hlth Center,8980250,diphenhydrAMINE 25 mg capsule,904530680,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,doxazosin 1 mg tablet,904552261,,250,$7.07 ,$7.07 ,$1.98 ,$6.47 ,$4.95 ,$5.92 ,$6.47 ,$6.47 ,$6.47 ,$2.61 ,$4.24 ,$2.12 ,$6.36 ,$5.30 ,$5.66 ,$5.87
Hoopeston Regional Hlth Center,8980250,doxazosin 2 mg tablet,904552361,,250,$6.85 ,$6.85 ,$1.92 ,$6.27 ,$4.80 ,$5.73 ,$6.27 ,$6.27 ,$6.27 ,$2.52 ,$4.11 ,$2.06 ,$6.17 ,$5.14 ,$5.48 ,$5.69
Hoopeston Regional Hlth Center,8980250,FLUoxetine 10 mg capsule,904578461,,250,$13.60 ,$13.60 ,$3.81 ,$12.44 ,$9.52 ,$11.38 ,$12.44 ,$12.44 ,$12.44 ,$5.01 ,$8.16 ,$4.08 ,$12.24 ,$10.20 ,$10.88 ,$11.29
Hoopeston Regional Hlth Center,8980250,cholecalciferol (vitamin D3) 10 mcg (400 unit) tablet,904582360,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,"cholecalciferol (vitamin D3) 25 mcg (1,000 unit) tablet",904582460,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,LORazepam 1 mg tablet,904600860,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,demeclocycline 150 mg tablet,904618061,,250,$30.69 ,$30.69 ,$8.59 ,$28.08 ,$21.48 ,$25.69 ,$28.08 ,$28.08 ,$28.08 ,$11.31 ,$18.41 ,$9.21 ,$27.62 ,$23.02 ,$24.55 ,$25.47
Hoopeston Regional Hlth Center,8980250,atorvastatin 10 mg tablet,904629061,,250,$4.66 ,$4.66 ,$1.30 ,$4.26 ,$3.26 ,$3.90 ,$4.26 ,$4.26 ,$4.26 ,$1.72 ,$2.80 ,$1.40 ,$4.19 ,$3.50 ,$3.73 ,$3.87
Hoopeston Regional Hlth Center,8980250,risperiDONE 1 mg tablet,904635961,,250,$23.60 ,$23.60 ,$6.61 ,$21.59 ,$16.52 ,$19.75 ,$21.59 ,$21.59 ,$21.59 ,$8.70 ,$14.16 ,$7.08 ,$21.24 ,$17.70 ,$18.88 ,$19.59
Hoopeston Regional Hlth Center,8980250,tiZANidine 4 mg tablet,904641861,,250,$10.55 ,$10.55 ,$2.95 ,$9.65 ,$7.39 ,$8.83 ,$9.65 ,$9.65 ,$9.65 ,$3.89 ,$6.33 ,$3.17 ,$9.50 ,$7.91 ,$8.44 ,$8.76
Hoopeston Regional Hlth Center,8980250,polyethylene glycol 3350 17 gram oral powder packet,904642281,,250,$2.62 ,$2.62 ,$0.73 ,$2.40 ,$1.83 ,$2.19 ,$2.40 ,$2.40 ,$2.40 ,$0.97 ,$1.57 ,$0.79 ,$2.36 ,$1.97 ,$2.10 ,$2.17
Hoopeston Regional Hlth Center,8980250,docusate sodium 100 mg capsule,904645780,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,carbamide peroxide 6.5 % ear drops,904662735,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,QUEtiapine 25 mg tablet,904663861,,250,$3.95 ,$3.95 ,$1.11 ,$3.61 ,$2.77 ,$3.31 ,$3.61 ,$3.61 ,$3.61 ,$1.46 ,$2.37 ,$1.19 ,$3.56 ,$2.96 ,$3.16 ,$3.28
Hoopeston Regional Hlth Center,8980250,acetaminophen 500 mg tablet,904673080,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,"bisacodyL 5 mg tablet,delayed release",904674880,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,oxymetazoline 0.05 % nasal spray,904676130,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,aspirin 325 mg tablet,904680940,,250,$2.37 ,$2.37 ,$0.66 ,$2.17 ,$1.66 ,$1.98 ,$2.17 ,$2.17 ,$2.17 ,$0.87 ,$1.42 ,$0.71 ,$2.13 ,$1.78 ,$1.90 ,$1.97
Hoopeston Regional Hlth Center,8980250,ibuprofen 200 mg tablet,904791580,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,calcium gluconate 2.5 % topical gel,7768306306,,250,$188.73 ,$188.73 ,$52.84 ,$172.69 ,$132.11 ,$157.97 ,$172.69 ,$172.69 ,$172.69 ,$69.55 ,$113.24 ,$56.62 ,$169.86 ,$141.55 ,$150.98 ,$156.65
Hoopeston Regional Hlth Center,8980250,Lidocaine 2.5 % Ointment,9999040070,,250,$57.77 ,$57.77 ,$16.18 ,$52.86 ,$40.44 ,$48.35 ,$52.86 ,$52.86 ,$52.86 ,$21.29 ,$34.66 ,$17.33 ,$51.99 ,$43.33 ,$46.22 ,$47.95
Hoopeston Regional Hlth Center,8980250,dextrose 50 % in water (D50W) intravenous syringe,9999040101,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,chlorhexidine gluconate 0.12 % mouthwash,9999066794,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,phenytoin 100 mg/4 mL oral suspension,9999107563,,250,$9.60 ,$9.60 ,$2.69 ,$8.78 ,$6.72 ,$8.04 ,$8.78 ,$8.78 ,$8.78 ,$3.54 ,$5.76 ,$2.88 ,$8.64 ,$7.20 ,$7.68 ,$7.97
Hoopeston Regional Hlth Center,8980250,iodine strong (Lugols) 5 % oral solution,9999130310,,250,$43.57 ,$43.57 ,$12.20 ,$39.87 ,$30.50 ,$36.47 ,$39.87 ,$39.87 ,$39.87 ,$16.06 ,$26.14 ,$13.07 ,$39.21 ,$32.68 ,$34.86 ,$36.16
Hoopeston Regional Hlth Center,8980250,mineral oil (bulk),9999149027,,250,$14.96 ,$14.96 ,$4.19 ,$13.69 ,$10.47 ,$12.52 ,$13.69 ,$13.69 ,$13.69 ,$5.51 ,$8.98 ,$4.49 ,$13.46 ,$11.22 ,$11.97 ,$12.42
Hoopeston Regional Hlth Center,8980250,,9999400202,,250,"$2,267.25 ","$2,267.25 ",$634.83 ,"$2,074.53 ","$1,587.08 ","$1,897.69 ","$2,074.53 ","$2,074.53 ","$2,074.53 ",$835.48 ,"$1,360.35 ",$680.18 ,"$2,040.53 ","$1,700.44 ","$1,813.80 ","$1,881.82 "
Hoopeston Regional Hlth Center,8980250,,9999400213,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,acetaminophen 300 mg-codeine 30 mg/12.5 mL (12.5 mL) oral solution,9999401056,,250,$14.45 ,$14.45 ,$4.05 ,$13.22 ,$10.12 ,$12.09 ,$13.22 ,$13.22 ,$13.22 ,$5.32 ,$8.67 ,$4.34 ,$13.01 ,$10.84 ,$11.56 ,$11.99
Hoopeston Regional Hlth Center,8980250,,9999401203,,250,$13.98 ,$13.98 ,$3.91 ,$12.79 ,$9.79 ,$11.70 ,$12.79 ,$12.79 ,$12.79 ,$5.15 ,$8.39 ,$4.19 ,$12.58 ,$10.49 ,$11.18 ,$11.60
Hoopeston Regional Hlth Center,8980250,pyridoxine (vitamin B6) 50 mg tablet,10006070012,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,"esmolol 2,000 mg/100 mL (20 mg/mL) in sodium chloride,esmolol 2,000 mg/100 mL (20 mg/mL) in sterile water",10019007587,,250,"$3,522.75 ","$3,522.75 ",$986.37 ,"$3,223.32 ","$2,465.93 ","$2,948.54 ","$3,223.32 ","$3,223.32 ","$3,223.32 ","$1,298.13 ","$2,113.65 ","$1,056.83 ","$3,170.48 ","$2,642.06 ","$2,818.20 ","$2,923.88 "
Hoopeston Regional Hlth Center,8980250,niCARdipine 40 mg/200 mL(0.2 mg/ml) in sod chlor(iso) intravenous soln,10122032510,,250,"$1,423.48 ","$1,423.48 ",$398.57 ,"$1,302.48 ",$996.44 ,"$1,191.45 ","$1,302.48 ","$1,302.48 ","$1,302.48 ",$524.55 ,$854.09 ,$427.04 ,"$1,281.13 ","$1,067.61 ","$1,138.78 ","$1,181.49 "
Hoopeston Regional Hlth Center,8980250,butamben-tetracaine-benzocaine 2 %-2 %-14 % (200 mg/sec) topical spray,10223020103,,250,$19.22 ,$19.22 ,$5.38 ,$17.59 ,$13.45 ,$16.09 ,$17.59 ,$17.59 ,$17.59 ,$7.08 ,$11.53 ,$5.77 ,$17.30 ,$14.42 ,$15.38 ,$15.95
Hoopeston Regional Hlth Center,8980250,"buPROPion HCL XL 150 mg 24 hr tablet, extended release",10370010103,,250,$24.57 ,$24.57 ,$6.88 ,$22.48 ,$17.20 ,$20.57 ,$22.48 ,$22.48 ,$22.48 ,$9.05 ,$14.74 ,$7.37 ,$22.11 ,$18.43 ,$19.66 ,$20.39
Hoopeston Regional Hlth Center,8980250,peg-electrolyte solution 420 gram oral solution,10572030201,,250,$132.81 ,$132.81 ,$37.19 ,$121.52 ,$92.97 ,$111.16 ,$121.52 ,$121.52 ,$121.52 ,$48.94 ,$79.69 ,$39.84 ,$119.53 ,$99.61 ,$106.25 ,$110.23
Hoopeston Regional Hlth Center,8980250,hydrOXYzine HCL 10 mg tablet,10702001001,,250,$5.28 ,$5.28 ,$1.48 ,$4.83 ,$3.70 ,$4.42 ,$4.83 ,$4.83 ,$4.83 ,$1.95 ,$3.17 ,$1.58 ,$4.75 ,$3.96 ,$4.22 ,$4.38
Hoopeston Regional Hlth Center,8980250,hydrOXYzine HCL 25 mg tablet,10702001110,,250,$6.27 ,$6.27 ,$1.76 ,$5.74 ,$4.39 ,$5.25 ,$5.74 ,$5.74 ,$5.74 ,$2.31 ,$3.76 ,$1.88 ,$5.64 ,$4.70 ,$5.02 ,$5.20
Hoopeston Regional Hlth Center,8980250,sodium polystyrene sulfonate oral powder,10702003615,,250,$65.31 ,$65.31 ,$18.29 ,$59.76 ,$45.72 ,$54.66 ,$59.76 ,$59.76 ,$59.76 ,$24.07 ,$39.19 ,$19.59 ,$58.78 ,$48.98 ,$52.25 ,$54.21
Hoopeston Regional Hlth Center,8980250,hydrocodone-homatropine 5 mg-1.5 mg/5 mL oral syrup,10702015016,,250,$12.29 ,$12.29 ,$3.44 ,$11.25 ,$8.60 ,$10.29 ,$11.25 ,$11.25 ,$11.25 ,$4.53 ,$7.37 ,$3.69 ,$11.06 ,$9.22 ,$9.83 ,$10.20
Hoopeston Regional Hlth Center,8980250,"prednisoLONE acetate 0.12 % eye drops,suspension",11980017405,,250,$917.93 ,$917.93 ,$257.02 ,$839.91 ,$642.55 ,$768.31 ,$839.91 ,$839.91 ,$839.91 ,$338.26 ,$550.76 ,$275.38 ,$826.14 ,$688.45 ,$734.34 ,$761.88
Hoopeston Regional Hlth Center,8980250,"bacitracin-polymyxin B 500 unit-10,000 unit/gram topical packet",12547023813,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,silver nitrate applicators 75 %-25 % topical stick,12870000101,,250,$5.88 ,$5.88 ,$1.65 ,$5.38 ,$4.12 ,$4.92 ,$5.38 ,$5.38 ,$5.38 ,$2.17 ,$3.53 ,$1.76 ,$5.29 ,$4.41 ,$4.70 ,$4.88
Hoopeston Regional Hlth Center,8980250,mirtazapine 30 mg tablet,13107000334,,250,$15.22 ,$15.22 ,$4.26 ,$13.93 ,$10.65 ,$12.74 ,$13.93 ,$13.93 ,$13.93 ,$5.61 ,$9.13 ,$4.57 ,$13.70 ,$11.42 ,$12.18 ,$12.63
Hoopeston Regional Hlth Center,8980250,mirtazapine 15 mg tablet,13107003134,,250,$14.91 ,$14.91 ,$4.17 ,$13.64 ,$10.44 ,$12.48 ,$13.64 ,$13.64 ,$13.64 ,$5.49 ,$8.95 ,$4.47 ,$13.42 ,$11.18 ,$11.93 ,$12.38
Hoopeston Regional Hlth Center,8980250,pramipexole 0.125 mg tablet,13668009190,,250,$16.08 ,$16.08 ,$4.50 ,$14.71 ,$11.26 ,$13.46 ,$14.71 ,$14.71 ,$14.71 ,$5.93 ,$9.65 ,$4.82 ,$14.47 ,$12.06 ,$12.86 ,$13.35
Hoopeston Regional Hlth Center,8980250,pramipexole 0.25 mg tablet,13668009290,,250,$16.03 ,$16.03 ,$4.49 ,$14.67 ,$11.22 ,$13.42 ,$14.67 ,$14.67 ,$14.67 ,$5.91 ,$9.62 ,$4.81 ,$14.43 ,$12.02 ,$12.82 ,$13.30
Hoopeston Regional Hlth Center,8980250,pramipexole 1 mg tablet,13668009490,,250,$16.08 ,$16.08 ,$4.50 ,$14.71 ,$11.26 ,$13.46 ,$14.71 ,$14.71 ,$14.71 ,$5.93 ,$9.65 ,$4.82 ,$14.47 ,$12.06 ,$12.86 ,$13.35
Hoopeston Regional Hlth Center,8980250,"felodipine ER 5 mg tablet,extended release 24 hr",13668013301,,250,$9.37 ,$9.37 ,$2.62 ,$8.57 ,$6.56 ,$7.84 ,$8.57 ,$8.57 ,$8.57 ,$3.45 ,$5.62 ,$2.81 ,$8.43 ,$7.03 ,$7.50 ,$7.78
Hoopeston Regional Hlth Center,8980250,rosuvastatin 10 mg tablet,13668018090,,250,$39.46 ,$39.46 ,$11.05 ,$36.11 ,$27.62 ,$33.03 ,$36.11 ,$36.11 ,$36.11 ,$14.54 ,$23.68 ,$11.84 ,$35.51 ,$29.60 ,$31.57 ,$32.75
Hoopeston Regional Hlth Center,8980250,moxifloxacin 400 mg tablet,13668020130,,250,$103.33 ,$103.33 ,$28.93 ,$94.55 ,$72.33 ,$86.49 ,$94.55 ,$94.55 ,$94.55 ,$38.08 ,$62.00 ,$31.00 ,$93.00 ,$77.50 ,$82.66 ,$85.76
Hoopeston Regional Hlth Center,8980250,losartan 50 mg tablet,13668040990,,250,$12.86 ,$12.86 ,$3.60 ,$11.77 ,$9.00 ,$10.76 ,$11.77 ,$11.77 ,$11.77 ,$4.74 ,$7.72 ,$3.86 ,$11.57 ,$9.65 ,$10.29 ,$10.67
Hoopeston Regional Hlth Center,8980250,dapsone 25 mg tablet,13925050430,,250,$13.82 ,$13.82 ,$3.87 ,$12.65 ,$9.67 ,$11.57 ,$12.65 ,$12.65 ,$12.65 ,$5.09 ,$8.29 ,$4.15 ,$12.44 ,$10.37 ,$11.06 ,$11.47
Hoopeston Regional Hlth Center,8980250,ciprofloxacin 500 mg tablet,16571041210,,250,$26.32 ,$26.32 ,$7.37 ,$24.08 ,$18.42 ,$22.03 ,$24.08 ,$24.08 ,$24.08 ,$9.70 ,$15.79 ,$7.90 ,$23.69 ,$19.74 ,$21.06 ,$21.85
Hoopeston Regional Hlth Center,8980250,tetracaine HCl (PF) 1 % (10 mg/mL) injection solution,17478004532,,250,$462.00 ,$462.00 ,$129.36 ,$422.73 ,$323.40 ,$386.69 ,$422.73 ,$422.73 ,$422.73 ,$170.25 ,$277.20 ,$138.60 ,$415.80 ,$346.50 ,$369.60 ,$383.46
Hoopeston Regional Hlth Center,8980250,SUFentanil citrate 50 mcg/mL intravenous solution,17478005001,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,SUFentanil citrate 50 mcg/mL intravenous solution,17478005002,,250,$58.72 ,$58.72 ,$16.44 ,$53.73 ,$41.10 ,$49.15 ,$53.73 ,$53.73 ,$53.73 ,$21.64 ,$35.23 ,$17.62 ,$52.85 ,$44.04 ,$46.98 ,$48.74
Hoopeston Regional Hlth Center,8980250,SUFentanil citrate 50 mcg/mL intravenous solution,17478005005,,250,$117.56 ,$117.56 ,$32.92 ,$107.57 ,$82.29 ,$98.40 ,$107.57 ,$107.57 ,$107.57 ,$43.32 ,$70.54 ,$35.27 ,$105.80 ,$88.17 ,$94.05 ,$97.57
Hoopeston Regional Hlth Center,8980250,erythromycin 5 mg/gram (0.5 %) eye ointment,17478007031,J3490,250,$62.96 ,$62.96 ,$17.63 ,$57.61 ,$44.07 ,$52.70 ,$57.61 ,$57.61 ,$57.61 ,$23.20 ,$37.78 ,$18.89 ,$56.66 ,$47.22 ,$50.37 ,$52.26
Hoopeston Regional Hlth Center,8980250,erythromycin 5 mg/gram (0.5 %) eye ointment,17478007035,J3490,250,$97.02 ,$97.02 ,$27.17 ,$88.77 ,$67.91 ,$81.21 ,$88.77 ,$88.77 ,$88.77 ,$35.75 ,$58.21 ,$29.11 ,$87.32 ,$72.77 ,$77.62 ,$80.53
Hoopeston Regional Hlth Center,8980250,phenylephrine 10 % eye drops,17478020605,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,atropine 1 % eye drops,17478021505,,250,$293.02 ,$293.02 ,$82.05 ,$268.11 ,$205.11 ,$245.26 ,$268.11 ,$268.11 ,$268.11 ,$107.98 ,$175.81 ,$87.91 ,$263.72 ,$219.77 ,$234.42 ,$243.21
Hoopeston Regional Hlth Center,8980250,fluorescein 500 mg/2 mL (25 %) intravenous solution,17478025020,,250,$268.94 ,$268.94 ,$75.30 ,$246.08 ,$188.26 ,$225.10 ,$246.08 ,$246.08 ,$246.08 ,$99.10 ,$161.36 ,$80.68 ,$242.05 ,$201.71 ,$215.15 ,$223.22
Hoopeston Regional Hlth Center,8980250,proparacaine 0.5 % eye drops,17478026312,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,gentamicin 0.3 % (3 mg/gram) eye ointment,17478028435,,250,$179.80 ,$179.80 ,$50.34 ,$164.52 ,$125.86 ,$150.49 ,$164.52 ,$164.52 ,$164.52 ,$66.26 ,$107.88 ,$53.94 ,$161.82 ,$134.85 ,$143.84 ,$149.23
Hoopeston Regional Hlth Center,8980250,timoloL maleate 0.5 % eye drops,17478028811,,250,$171.72 ,$171.72 ,$48.08 ,$157.12 ,$120.20 ,$143.73 ,$157.12 ,$157.12 ,$157.12 ,$63.28 ,$103.03 ,$51.52 ,$154.55 ,$128.79 ,$137.38 ,$142.53
Hoopeston Regional Hlth Center,8980250,azithromycin 1 % eye drops,17478030703,,250,$23.48 ,$23.48 ,$6.57 ,$21.48 ,$16.44 ,$19.65 ,$21.48 ,$21.48 ,$21.48 ,$8.65 ,$14.09 ,$7.04 ,$21.13 ,$17.61 ,$18.78 ,$19.49
Hoopeston Regional Hlth Center,8980250,fluorescein 1 mg eye strips,17478040401,,250,$3.21 ,$3.21 ,$0.90 ,$2.94 ,$2.25 ,$2.69 ,$2.94 ,$2.94 ,$2.94 ,$1.18 ,$1.93 ,$0.96 ,$2.89 ,$2.41 ,$2.57 ,$2.66
Hoopeston Regional Hlth Center,8980250,ethanol (ethyl alcohol) 98 % injection solution,17478050305,,250,"$2,076.70 ","$2,076.70 ",$581.48 ,"$1,900.18 ","$1,453.69 ","$1,738.20 ","$1,900.18 ","$1,900.18 ","$1,900.18 ",$765.26 ,"$1,246.02 ",$623.01 ,"$1,869.03 ","$1,557.53 ","$1,661.36 ","$1,723.66 "
Hoopeston Regional Hlth Center,8980250,physostigmine 1 mg/mL injection solution,17478051002,,250,$475.11 ,$475.11 ,$133.03 ,$434.73 ,$332.58 ,$397.67 ,$434.73 ,$434.73 ,$434.73 ,$175.08 ,$285.07 ,$142.53 ,$427.60 ,$356.33 ,$380.09 ,$394.34
Hoopeston Regional Hlth Center,8980250,sodium chloride 5 % eye ointment,17478062235,,250,$70.17 ,$70.17 ,$19.65 ,$64.21 ,$49.12 ,$58.73 ,$64.21 ,$64.21 ,$64.21 ,$25.86 ,$42.10 ,$21.05 ,$63.15 ,$52.63 ,$56.14 ,$58.24
Hoopeston Regional Hlth Center,8980250,indocyanine green 25 mg solution for injection,17478070102,,250,$600.65 ,$600.65 ,$168.18 ,$549.59 ,$420.46 ,$502.74 ,$549.59 ,$549.59 ,$549.59 ,$221.34 ,$360.39 ,$180.20 ,$540.59 ,$450.49 ,$480.52 ,$498.54
Hoopeston Regional Hlth Center,8980250,Lidocaine 2 % Mucosal Gel,17478071110,,250,$52.39 ,$52.39 ,$14.67 ,$47.94 ,$36.67 ,$43.85 ,$47.94 ,$47.94 ,$47.94 ,$19.31 ,$31.43 ,$15.72 ,$47.15 ,$39.29 ,$41.91 ,$43.48
Hoopeston Regional Hlth Center,8980250,lidocaine HCL 2 % mucosal jelly,17478071130,,250,$619.03 ,$619.03 ,$173.33 ,$566.41 ,$433.32 ,$518.13 ,$566.41 ,$566.41 ,$566.41 ,$228.11 ,$371.42 ,$185.71 ,$557.13 ,$464.27 ,$495.22 ,$513.79
Hoopeston Regional Hlth Center,8980250,lidocaine HCL 2 % mucosal jelly,17478071131,,250,$52.39 ,$52.39 ,$14.67 ,$47.94 ,$36.67 ,$43.85 ,$47.94 ,$47.94 ,$47.94 ,$19.31 ,$31.43 ,$15.72 ,$47.15 ,$39.29 ,$41.91 ,$43.48
Hoopeston Regional Hlth Center,8980250,ofloxacin 0.3 % eye drops,17478071310,,250,$118.55 ,$118.55 ,$33.19 ,$108.47 ,$82.99 ,$99.23 ,$108.47 ,$108.47 ,$108.47 ,$43.69 ,$71.13 ,$35.57 ,$106.70 ,$88.91 ,$94.84 ,$98.40
Hoopeston Regional Hlth Center,8980250,dilTIAZem 5 mg/mL intravenous solution,17478093710,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,povidone-iodine 5 % kit,17518006004,,250,$26.40 ,$26.40 ,$7.39 ,$24.16 ,$18.48 ,$22.10 ,$24.16 ,$24.16 ,$24.16 ,$9.73 ,$15.84 ,$7.92 ,$23.76 ,$19.80 ,$21.12 ,$21.91
Hoopeston Regional Hlth Center,8980250,"felodipine ER 2.5 mg tablet,extended release 24 hr",23155004801,,250,$9.37 ,$9.37 ,$2.62 ,$8.57 ,$6.56 ,$7.84 ,$8.57 ,$8.57 ,$8.57 ,$3.45 ,$5.62 ,$2.81 ,$8.43 ,$7.03 ,$7.50 ,$7.78
Hoopeston Regional Hlth Center,8980250,propranoloL 10 mg tablet,23155011001,,250,$4.23 ,$4.23 ,$1.18 ,$3.87 ,$2.96 ,$3.54 ,$3.87 ,$3.87 ,$3.87 ,$1.56 ,$2.54 ,$1.27 ,$3.81 ,$3.17 ,$3.38 ,$3.51
Hoopeston Regional Hlth Center,8980250,propranoloL 60 mg tablet,23155011301,,250,$10.45 ,$10.45 ,$2.93 ,$9.56 ,$7.32 ,$8.75 ,$9.56 ,$9.56 ,$9.56 ,$3.85 ,$6.27 ,$3.14 ,$9.41 ,$7.84 ,$8.36 ,$8.67
Hoopeston Regional Hlth Center,8980250,tobramycin 0.3 % eye drops,24208029005,,250,$85.56 ,$85.56 ,$23.96 ,$78.29 ,$59.89 ,$71.61 ,$78.29 ,$78.29 ,$78.29 ,$31.53 ,$51.34 ,$25.67 ,$77.00 ,$64.17 ,$68.45 ,$71.01
Hoopeston Regional Hlth Center,8980250,"vit A 1,000 unit-C 200 mg-E 60 unit-lutein 2 mg and minerals tablet",24208038762,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,ofloxacin 0.3 % ear drops,24208041005,,250,$739.91 ,$739.91 ,$207.17 ,$677.02 ,$517.94 ,$619.30 ,$677.02 ,$677.02 ,$677.02 ,$272.66 ,$443.95 ,$221.97 ,$665.92 ,$554.93 ,$591.93 ,$614.13
Hoopeston Regional Hlth Center,8980250,levobunoloL 0.5 % eye drops,24208050505,,250,$133.65 ,$133.65 ,$37.42 ,$122.29 ,$93.56 ,$111.87 ,$122.29 ,$122.29 ,$122.29 ,$49.25 ,$80.19 ,$40.10 ,$120.29 ,$100.24 ,$106.92 ,$110.93
Hoopeston Regional Hlth Center,8980250,"neomycin-polymyxin-hydrocort 3.5 mg/mL-10,000 unit/mL-1 % ear solution",24208063110,,250,$490.14 ,$490.14 ,$137.24 ,$448.48 ,$343.10 ,$410.25 ,$448.48 ,$448.48 ,$448.48 ,$180.62 ,$294.08 ,$147.04 ,$441.13 ,$367.61 ,$392.11 ,$406.82
Hoopeston Regional Hlth Center,8980250,dexAMETHasone sodium phosphate 0.1 % eye drops,24208072002,,250,$322.38 ,$322.38 ,$90.27 ,$294.98 ,$225.67 ,$269.83 ,$294.98 ,$294.98 ,$294.98 ,$118.80 ,$193.43 ,$96.71 ,$290.14 ,$241.79 ,$257.90 ,$267.58
Hoopeston Regional Hlth Center,8980250,"neomycin-bacitracin-polymyxn 3.5 mg-400 unit-10,000 unit/gram eye oint",24208078055,,250,$253.19 ,$253.19 ,$70.89 ,$231.67 ,$177.23 ,$211.92 ,$231.67 ,$231.67 ,$231.67 ,$93.30 ,$151.91 ,$75.96 ,$227.87 ,$189.89 ,$202.55 ,$210.15
Hoopeston Regional Hlth Center,8980250,"neomycin-bacitracin-poly-HC 3.5 mg-400-10,000 unit/g-1 % eye ointment",24208078555,,250,$286.22 ,$286.22 ,$80.14 ,$261.89 ,$200.35 ,$239.57 ,$261.89 ,$261.89 ,$261.89 ,$105.47 ,$171.73 ,$85.87 ,$257.60 ,$214.67 ,$228.98 ,$237.56
Hoopeston Regional Hlth Center,8980250,"neomycin 1.75 mg-polymyxin 10,000 unit-gramicidin 0.025mg/mL eye drops",24208079062,,250,$306.44 ,$306.44 ,$85.80 ,$280.39 ,$214.51 ,$256.49 ,$280.39 ,$280.39 ,$280.39 ,$112.92 ,$183.86 ,$91.93 ,$275.80 ,$229.83 ,$245.15 ,$254.35
Hoopeston Regional Hlth Center,8980250,"neomycin-polymyxin-dexameth 3.5 mg/mL-10,000 unit/mL-0.1% eye drops",24208083060,,250,$113.52 ,$113.52 ,$31.79 ,$103.87 ,$79.46 ,$95.02 ,$103.87 ,$103.87 ,$103.87 ,$41.83 ,$68.11 ,$34.06 ,$102.17 ,$85.14 ,$90.82 ,$94.22
Hoopeston Regional Hlth Center,8980250,"erythromycin 333 mg tablet,delayed release",24338012413,,250,$47.06 ,$47.06 ,$13.18 ,$43.06 ,$32.94 ,$39.39 ,$43.06 ,$43.06 ,$43.06 ,$17.34 ,$28.24 ,$14.12 ,$42.35 ,$35.30 ,$37.65 ,$39.06
Hoopeston Regional Hlth Center,8980250,erythromycin ethylsuccinate 200 mg/5 mL oral powder for suspension,24338013402,,250,$85.82 ,$85.82 ,$24.03 ,$78.53 ,$60.07 ,$71.83 ,$78.53 ,$78.53 ,$78.53 ,$31.62 ,$51.49 ,$25.75 ,$77.24 ,$64.37 ,$68.66 ,$71.23
Hoopeston Regional Hlth Center,8980250,"peg 400-hypromellose-glycerin 1 %-0.2 %-0.2 % eye drops,dextran 70-hypromellose 0.1 %-0.3 % eye drops,polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops,polyvinyl alcohol 1.4 % eye drops,peg 400-propylene glycol 0.4 %-0.3 % eye drops",24385000605,,250,$37.20 ,$37.20 ,$10.42 ,$34.04 ,$26.04 ,$31.14 ,$34.04 ,$34.04 ,$34.04 ,$13.71 ,$22.32 ,$11.16 ,$33.48 ,$27.90 ,$29.76 ,$30.88
Hoopeston Regional Hlth Center,8980250,tetrahydrozoline 0.05 % eye drops,24385007505,,250,$27.86 ,$27.86 ,$7.80 ,$25.49 ,$19.50 ,$23.32 ,$25.49 ,$25.49 ,$25.49 ,$10.27 ,$16.72 ,$8.36 ,$25.07 ,$20.90 ,$22.29 ,$23.12
Hoopeston Regional Hlth Center,8980250,lidocaine 2 % mucosal jelly in applicator,25021067377,,250,$37.85 ,$37.85 ,$10.60 ,$34.63 ,$26.50 ,$31.68 ,$34.63 ,$34.63 ,$34.63 ,$13.95 ,$22.71 ,$11.36 ,$34.07 ,$28.39 ,$30.28 ,$31.42
Hoopeston Regional Hlth Center,8980250,"ranolazine ER 500 mg tablet,extended release,12 hr",27241012502,,250,$31.73 ,$31.73 ,$8.88 ,$29.03 ,$22.21 ,$26.56 ,$29.03 ,$29.03 ,$29.03 ,$11.69 ,$19.04 ,$9.52 ,$28.56 ,$23.80 ,$25.38 ,$26.34
Hoopeston Regional Hlth Center,8980250,acetylcysteine 600 mg capsule,27434000211,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,dantrolene 20 mg intravenous solution,27505000367,,250,$416.14 ,$416.14 ,$116.52 ,$380.77 ,$291.30 ,$348.31 ,$380.77 ,$380.77 ,$380.77 ,$153.35 ,$249.68 ,$124.84 ,$374.53 ,$312.11 ,$332.91 ,$345.40
Hoopeston Regional Hlth Center,8980250,rosuvastatin 40 mg tablet,27808015801,,250,$39.46 ,$39.46 ,$11.05 ,$36.11 ,$27.62 ,$33.03 ,$36.11 ,$36.11 ,$36.11 ,$14.54 ,$23.68 ,$11.84 ,$35.51 ,$29.60 ,$31.57 ,$32.75
Hoopeston Regional Hlth Center,8980250,efavirenz 600 mg tablet,31722050430,,250,$138.57 ,$138.57 ,$38.80 ,$126.79 ,$97.00 ,$115.98 ,$126.79 ,$126.79 ,$126.79 ,$51.06 ,$83.14 ,$41.57 ,$124.71 ,$103.93 ,$110.86 ,$115.01
Hoopeston Regional Hlth Center,8980250,stavudine 20 mg capsule,31722051660,,250,$34.99 ,$34.99 ,$9.80 ,$32.02 ,$24.49 ,$29.29 ,$32.02 ,$32.02 ,$32.02 ,$12.89 ,$20.99 ,$10.50 ,$31.49 ,$26.24 ,$27.99 ,$29.04
Hoopeston Regional Hlth Center,8980250,finasteride 5 mg tablet,31722052590,,250,$19.17 ,$19.17 ,$5.37 ,$17.54 ,$13.42 ,$16.05 ,$17.54 ,$17.54 ,$17.54 ,$7.06 ,$11.50 ,$5.75 ,$17.25 ,$14.38 ,$15.34 ,$15.91
Hoopeston Regional Hlth Center,8980250,torsemide 10 mg tablet,31722053001,,250,$5.61 ,$5.61 ,$1.57 ,$5.13 ,$3.93 ,$4.70 ,$5.13 ,$5.13 ,$5.13 ,$2.07 ,$3.37 ,$1.68 ,$5.05 ,$4.21 ,$4.49 ,$4.66
Hoopeston Regional Hlth Center,8980250,valACYclovir 500 mg tablet,31722070430,,250,$33.43 ,$33.43 ,$9.36 ,$30.59 ,$23.40 ,$27.98 ,$30.59 ,$30.59 ,$30.59 ,$12.32 ,$20.06 ,$10.03 ,$30.09 ,$25.07 ,$26.74 ,$27.75
Hoopeston Regional Hlth Center,8980250,acyclovir 800 mg tablet,31722077801,,250,$21.98 ,$21.98 ,$6.15 ,$20.11 ,$15.39 ,$18.40 ,$20.11 ,$20.11 ,$20.11 ,$8.10 ,$13.19 ,$6.59 ,$19.78 ,$16.49 ,$17.58 ,$18.24
Hoopeston Regional Hlth Center,8980250,valsartan 80 mg tablet,33342006310,,250,$11.37 ,$11.37 ,$3.18 ,$10.40 ,$7.96 ,$9.52 ,$10.40 ,$10.40 ,$10.40 ,$4.19 ,$6.82 ,$3.41 ,$10.23 ,$8.53 ,$9.10 ,$9.44
Hoopeston Regional Hlth Center,8980250,memantine 10 mg tablet,33342029809,,250,$29.48 ,$29.48 ,$8.25 ,$26.97 ,$20.64 ,$24.67 ,$26.97 ,$26.97 ,$26.97 ,$10.86 ,$17.69 ,$8.84 ,$26.53 ,$22.11 ,$23.58 ,$24.47
Hoopeston Regional Hlth Center,8980250,bupivacaine (PF) 0.75 % (7.5 mg/mL) in 8.25 % dextrose injection,36000009210,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,"magnesium L-lactate ER 84 mg tablet,extended release",36765042019,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,sodium chloride-potassium chloride 287 mg-180 mg-15 mg tablet,38485086335,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,sodium hypochlorite 0.125 % solution,39328006412,,250,$83.33 ,$83.33 ,$23.33 ,$76.25 ,$58.33 ,$69.75 ,$76.25 ,$76.25 ,$76.25 ,$30.71 ,$50.00 ,$25.00 ,$75.00 ,$62.50 ,$66.66 ,$69.16
Hoopeston Regional Hlth Center,8980250,"neomycin 40 mg-polymyxin B 200,000 unit/mL GU irrigation solution",39822120105,,250,$109.71 ,$109.71 ,$30.72 ,$100.38 ,$76.80 ,$91.83 ,$100.38 ,$100.38 ,$100.38 ,$40.43 ,$65.83 ,$32.91 ,$98.74 ,$82.28 ,$87.77 ,$91.06
Hoopeston Regional Hlth Center,8980250,vecuronium bromide 10 mg intravenous solution,41616093144,,250,$94.31 ,$94.31 ,$26.41 ,$86.29 ,$66.02 ,$78.94 ,$86.29 ,$86.29 ,$86.29 ,$34.75 ,$56.59 ,$28.29 ,$84.88 ,$70.73 ,$75.45 ,$78.28
Hoopeston Regional Hlth Center,8980250,mycophenolate 500 mg intravenous solution,42023017204,,250,$469.49 ,$469.49 ,$131.46 ,$429.58 ,$328.64 ,$392.96 ,$429.58 ,$429.58 ,$429.58 ,$173.01 ,$281.69 ,$140.85 ,$422.54 ,$352.12 ,$375.59 ,$389.68
Hoopeston Regional Hlth Center,8980250,gabapentin 250 mg/5 mL oral solution,42192060816,,250,$25.96 ,$25.96 ,$7.27 ,$23.75 ,$18.17 ,$21.73 ,$23.75 ,$23.75 ,$23.75 ,$9.57 ,$15.58 ,$7.79 ,$23.36 ,$19.47 ,$20.77 ,$21.55
Hoopeston Regional Hlth Center,8980250,memantine 5 mg tablet,42292000506,,250,$29.51 ,$29.51 ,$8.26 ,$27.00 ,$20.66 ,$24.70 ,$27.00 ,$27.00 ,$27.00 ,$10.87 ,$17.71 ,$8.85 ,$26.56 ,$22.13 ,$23.61 ,$24.49
Hoopeston Regional Hlth Center,8980250,hydrocortisone acetate 25 mg rectal suppository,42494030112,,250,$87.48 ,$87.48 ,$24.49 ,$80.04 ,$61.24 ,$73.22 ,$80.04 ,$80.04 ,$80.04 ,$32.24 ,$52.49 ,$26.24 ,$78.73 ,$65.61 ,$69.98 ,$72.61
Hoopeston Regional Hlth Center,8980250,hydrocortisone 10 mg tablet,42543014101,,250,$5.00 ,$5.00 ,$1.40 ,$4.58 ,$3.50 ,$4.19 ,$4.58 ,$4.58 ,$4.58 ,$1.84 ,$3.00 ,$1.50 ,$4.50 ,$3.75 ,$4.00 ,$4.15
Hoopeston Regional Hlth Center,8980250,hydrocortisone 20 mg tablet,42543014201,,250,$7.40 ,$7.40 ,$2.07 ,$6.77 ,$5.18 ,$6.19 ,$6.77 ,$6.77 ,$6.77 ,$2.73 ,$4.44 ,$2.22 ,$6.66 ,$5.55 ,$5.92 ,$6.14
Hoopeston Regional Hlth Center,8980250,liothyronine 25 mcg tablet,42794001912,,250,$7.46 ,$7.46 ,$2.09 ,$6.83 ,$5.22 ,$6.24 ,$6.83 ,$6.83 ,$6.83 ,$2.75 ,$4.48 ,$2.24 ,$6.71 ,$5.60 ,$5.97 ,$6.19
Hoopeston Regional Hlth Center,8980250,dofetilide 125 mcg capsule,42794004410,,250,$38.12 ,$38.12 ,$10.67 ,$34.88 ,$26.68 ,$31.91 ,$34.88 ,$34.88 ,$34.88 ,$14.05 ,$22.87 ,$11.44 ,$34.31 ,$28.59 ,$30.50 ,$31.64
Hoopeston Regional Hlth Center,8980250,meperidine 50 mg tablet,42806005030,,250,$161.40 ,$161.40 ,$45.19 ,$147.68 ,$112.98 ,$135.09 ,$147.68 ,$147.68 ,$147.68 ,$59.48 ,$96.84 ,$48.42 ,$145.26 ,$121.05 ,$129.12 ,$133.96
Hoopeston Regional Hlth Center,8980250,gemfibroziL 600 mg tablet,42806026005,,250,$13.12 ,$13.12 ,$3.67 ,$12.00 ,$9.18 ,$10.98 ,$12.00 ,$12.00 ,$12.00 ,$4.83 ,$7.87 ,$3.94 ,$11.81 ,$9.84 ,$10.50 ,$10.89
Hoopeston Regional Hlth Center,8980250,doxycycline hyclate 100 mg tablet,42806031205,,250,$29.66 ,$29.66 ,$8.30 ,$27.14 ,$20.76 ,$24.83 ,$27.14 ,$27.14 ,$27.14 ,$10.93 ,$17.80 ,$8.90 ,$26.69 ,$22.25 ,$23.73 ,$24.62
Hoopeston Regional Hlth Center,8980250,dutasteride 0.5 mg capsule,42806054930,,250,$29.33 ,$29.33 ,$8.21 ,$26.84 ,$20.53 ,$24.55 ,$26.84 ,$26.84 ,$26.84 ,$10.81 ,$17.60 ,$8.80 ,$26.40 ,$22.00 ,$23.46 ,$24.34
Hoopeston Regional Hlth Center,8980250,oxyCODONE 30 mg tablet,42858000501,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,fenofibrate 160 mg tablet,42858066045,,250,$15.75 ,$15.75 ,$4.41 ,$14.41 ,$11.03 ,$13.18 ,$14.41 ,$14.41 ,$14.41 ,$5.80 ,$9.45 ,$4.73 ,$14.18 ,$11.81 ,$12.60 ,$13.07
Hoopeston Regional Hlth Center,8980250,"morphine ER 100 mg tablet,extended release",42858080401,,250,$14.54 ,$14.54 ,$4.07 ,$13.30 ,$10.18 ,$12.17 ,$13.30 ,$13.30 ,$13.30 ,$5.36 ,$8.72 ,$4.36 ,$13.09 ,$10.91 ,$11.63 ,$12.07
Hoopeston Regional Hlth Center,8980250,hyoscyamine 0.125 mg sublingual tablet,43199001101,,250,$6.29 ,$6.29 ,$1.76 ,$5.76 ,$4.40 ,$5.26 ,$5.76 ,$5.76 ,$5.76 ,$2.32 ,$3.77 ,$1.89 ,$5.66 ,$4.72 ,$5.03 ,$5.22
Hoopeston Regional Hlth Center,8980250,"hyoscyamine ER 0.375 mg tablet,extended release,12 hr",43199001401,,250,$9.79 ,$9.79 ,$2.74 ,$8.96 ,$6.85 ,$8.19 ,$8.96 ,$8.96 ,$8.96 ,$3.61 ,$5.87 ,$2.94 ,$8.81 ,$7.34 ,$7.83 ,$8.13
Hoopeston Regional Hlth Center,8980250,trimethoprim 100 mg tablet,43386033001,,250,$5.52 ,$5.52 ,$1.55 ,$5.05 ,$3.86 ,$4.62 ,$5.05 ,$5.05 ,$5.05 ,$2.03 ,$3.31 ,$1.66 ,$4.97 ,$4.14 ,$4.42 ,$4.58
Hoopeston Regional Hlth Center,8980250,"orphenadrine citrate ER 100 mg tablet,extended release",43386048024,,250,$13.09 ,$13.09 ,$3.67 ,$11.98 ,$9.16 ,$10.96 ,$11.98 ,$11.98 ,$11.98 ,$4.82 ,$7.85 ,$3.93 ,$11.78 ,$9.82 ,$10.47 ,$10.86
Hoopeston Regional Hlth Center,8980250,"propranoloL ER 60 mg capsule,24 hr,extended release",43478090088,,250,$11.84 ,$11.84 ,$3.32 ,$10.83 ,$8.29 ,$9.91 ,$10.83 ,$10.83 ,$10.83 ,$4.36 ,$7.10 ,$3.55 ,$10.66 ,$8.88 ,$9.47 ,$9.83
Hoopeston Regional Hlth Center,8980250,rOPINIRole 0.5 mg tablet,43547026910,,250,$13.98 ,$13.98 ,$3.91 ,$12.79 ,$9.79 ,$11.70 ,$12.79 ,$12.79 ,$12.79 ,$5.15 ,$8.39 ,$4.19 ,$12.58 ,$10.49 ,$11.18 ,$11.60
Hoopeston Regional Hlth Center,8980250,donepeziL 10 mg tablet,43547027603,,250,$38.44 ,$38.44 ,$10.76 ,$35.17 ,$26.91 ,$32.17 ,$35.17 ,$35.17 ,$35.17 ,$14.17 ,$23.06 ,$11.53 ,$34.60 ,$28.83 ,$30.75 ,$31.91
Hoopeston Regional Hlth Center,8980250,donepeziL 10 mg tablet,43547027609,,250,$38.44 ,$38.44 ,$10.76 ,$35.17 ,$26.91 ,$32.17 ,$35.17 ,$35.17 ,$35.17 ,$14.17 ,$23.06 ,$11.53 ,$34.60 ,$28.83 ,$30.75 ,$31.91
Hoopeston Regional Hlth Center,8980250,"buPROPion HCL SR 100 mg tablet,12 hr sustained-release",43547028810,,250,$11.37 ,$11.37 ,$3.18 ,$10.40 ,$7.96 ,$9.52 ,$10.40 ,$10.40 ,$10.40 ,$4.19 ,$6.82 ,$3.41 ,$10.23 ,$8.53 ,$9.10 ,$9.44
Hoopeston Regional Hlth Center,8980250,fosinopriL 20 mg tablet,43547038709,,250,$7.88 ,$7.88 ,$2.21 ,$7.21 ,$5.52 ,$6.60 ,$7.21 ,$7.21 ,$7.21 ,$2.90 ,$4.73 ,$2.36 ,$7.09 ,$5.91 ,$6.30 ,$6.54
Hoopeston Regional Hlth Center,8980250,quinapriL 20 mg tablet,43547041209,,250,$8.03 ,$8.03 ,$2.25 ,$7.35 ,$5.62 ,$6.72 ,$7.35 ,$7.35 ,$7.35 ,$2.96 ,$4.82 ,$2.41 ,$7.23 ,$6.02 ,$6.42 ,$6.66
Hoopeston Regional Hlth Center,8980250,zinc oxide-white petrolatum 15 %-49 % topical ointment,43553325604,,250,$56.77 ,$56.77 ,$15.90 ,$51.94 ,$39.74 ,$47.52 ,$51.94 ,$51.94 ,$51.94 ,$20.92 ,$34.06 ,$17.03 ,$51.09 ,$42.58 ,$45.42 ,$47.12
Hoopeston Regional Hlth Center,8980250,pregabalin 25 mg capsule,43598029190,,250,$39.98 ,$39.98 ,$11.19 ,$36.58 ,$27.99 ,$33.46 ,$36.58 ,$36.58 ,$36.58 ,$14.73 ,$23.99 ,$11.99 ,$35.98 ,$29.99 ,$31.98 ,$33.18
Hoopeston Regional Hlth Center,8980250,pregabalin 50 mg capsule,43598029290,,250,$39.98 ,$39.98 ,$11.19 ,$36.58 ,$27.99 ,$33.46 ,$36.58 ,$36.58 ,$36.58 ,$14.73 ,$23.99 ,$11.99 ,$35.98 ,$29.99 ,$31.98 ,$33.18
Hoopeston Regional Hlth Center,8980250,pregabalin 75 mg capsule,43598029390,,250,$39.98 ,$39.98 ,$11.19 ,$36.58 ,$27.99 ,$33.46 ,$36.58 ,$36.58 ,$36.58 ,$14.73 ,$23.99 ,$11.99 ,$35.98 ,$29.99 ,$31.98 ,$33.18
Hoopeston Regional Hlth Center,8980250,whey protein isolate 6 gram-25 kcal/7 gram oral powder packet,43900028430,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,guar gum oral packet,43900097647,,250,$0.68 ,$0.68 ,$0.19 ,$0.62 ,$0.48 ,$0.57 ,$0.62 ,$0.62 ,$0.62 ,$0.25 ,$0.41 ,$0.20 ,$0.61 ,$0.51 ,$0.54 ,$0.56
Hoopeston Regional Hlth Center,8980250,indapamide 2.5 mg tablet,43975030410,,250,$9.55 ,$9.55 ,$2.67 ,$8.74 ,$6.69 ,$7.99 ,$8.74 ,$8.74 ,$8.74 ,$3.52 ,$5.73 ,$2.87 ,$8.60 ,$7.16 ,$7.64 ,$7.93
Hoopeston Regional Hlth Center,8980250,"esmolol 2,000 mg/100 mL (20 mg/mL) in sodium chloride,esmolol 2,000 mg/100 mL (20 mg/mL) in sterile water",44567081210,,250,$907.83 ,$907.83 ,$254.19 ,$830.66 ,$635.48 ,$759.85 ,$830.66 ,$830.66 ,$830.66 ,$334.54 ,$544.70 ,$272.35 ,$817.05 ,$680.87 ,$726.26 ,$753.50
Hoopeston Regional Hlth Center,8980250,gentamicin 0.1 % topical ointment,45802004635,,250,$251.08 ,$251.08 ,$70.30 ,$229.74 ,$175.76 ,$210.15 ,$229.74 ,$229.74 ,$229.74 ,$92.52 ,$150.65 ,$75.32 ,$225.97 ,$188.31 ,$200.86 ,$208.40
Hoopeston Regional Hlth Center,8980250,dibucaine 1 % topical ointment,45802005003,,250,$36.09 ,$36.09 ,$10.11 ,$33.02 ,$25.26 ,$30.21 ,$33.02 ,$33.02 ,$33.02 ,$13.30 ,$21.65 ,$10.83 ,$32.48 ,$27.07 ,$28.87 ,$29.95
Hoopeston Regional Hlth Center,8980250,gentamicin 0.1 % topical cream,45802005635,,250,$251.08 ,$251.08 ,$70.30 ,$229.74 ,$175.76 ,$210.15 ,$229.74 ,$229.74 ,$229.74 ,$92.52 ,$150.65 ,$75.32 ,$225.97 ,$188.31 ,$200.86 ,$208.40
Hoopeston Regional Hlth Center,8980250,"nystatin 100,000 unit/gram topical cream",45802005935,,250,$102.54 ,$102.54 ,$28.71 ,$93.82 ,$71.78 ,$85.83 ,$93.82 ,$93.82 ,$93.82 ,$37.79 ,$61.52 ,$30.76 ,$92.29 ,$76.91 ,$82.03 ,$85.11
Hoopeston Regional Hlth Center,8980250,triamcinolone acetonide 0.1 % topical cream,45802006435,J3490,250,$26.11 ,$26.11 ,$7.31 ,$23.89 ,$18.28 ,$21.85 ,$23.89 ,$23.89 ,$23.89 ,$9.62 ,$15.67 ,$7.83 ,$23.50 ,$19.58 ,$20.89 ,$21.67
Hoopeston Regional Hlth Center,8980250,"mesalamine 4 gram/60 mL enema,mesalamine rectal susp enema with cleansing wipes 4 gram/60 mL kit",45802009851,,250,$115.57 ,$115.57 ,$32.36 ,$105.75 ,$80.90 ,$96.73 ,$105.75 ,$105.75 ,$105.75 ,$42.59 ,$69.34 ,$34.67 ,$104.01 ,$86.68 ,$92.46 ,$95.92
Hoopeston Regional Hlth Center,8980250,"pseudoephedrine ER 120 mg tablet,extended release",45802010752,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,"neomycin-bacitracn Zn-polymyxn 3.5 mg-400 unit-5,000 unit top oint pkt",45802014370,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,fluticasone propionate 0.05 % topical cream,45802022235,,250,$124.63 ,$124.63 ,$34.90 ,$114.04 ,$87.24 ,$104.32 ,$114.04 ,$114.04 ,$114.04 ,$45.93 ,$74.78 ,$37.39 ,$112.17 ,$93.47 ,$99.70 ,$103.44
Hoopeston Regional Hlth Center,8980250,permethrin 5 % topical cream,45802026937,,250,$574.58 ,$574.58 ,$160.88 ,$525.74 ,$402.21 ,$480.92 ,$525.74 ,$525.74 ,$525.74 ,$211.73 ,$344.75 ,$172.37 ,$517.12 ,$430.94 ,$459.66 ,$476.90
Hoopeston Regional Hlth Center,8980250,diphenhydramine-zinc acetate 2 %-0.1 % topical cream,45802035803,,250,$25.17 ,$25.17 ,$7.05 ,$23.03 ,$17.62 ,$21.07 ,$23.03 ,$23.03 ,$23.03 ,$9.28 ,$15.10 ,$7.55 ,$22.65 ,$18.88 ,$20.14 ,$20.89
Hoopeston Regional Hlth Center,8980250,hydrocortisone 1 % topical cream,45802043803,,250,$25.17 ,$25.17 ,$7.05 ,$23.03 ,$17.62 ,$21.07 ,$23.03 ,$23.03 ,$23.03 ,$9.28 ,$15.10 ,$7.55 ,$22.65 ,$18.88 ,$20.14 ,$20.89
Hoopeston Regional Hlth Center,8980250,scopolamine 1 mg over 3 days transdermal patch,45802058046,,250,$88.65 ,$88.65 ,$24.82 ,$81.11 ,$62.06 ,$74.20 ,$81.11 ,$81.11 ,$81.11 ,$32.67 ,$53.19 ,$26.60 ,$79.79 ,$66.49 ,$70.92 ,$73.58
Hoopeston Regional Hlth Center,8980250,acetaminophen 650 mg rectal suppository,45802073030,,250,$0.93 ,$0.93 ,$0.26 ,$0.85 ,$0.65 ,$0.78 ,$0.85 ,$0.85 ,$0.85 ,$0.34 ,$0.56 ,$0.28 ,$0.84 ,$0.70 ,$0.74 ,$0.77
Hoopeston Regional Hlth Center,8980250,acetaminophen 650 mg rectal suppository,45802073032,,250,$0.83 ,$0.83 ,$0.23 ,$0.76 ,$0.58 ,$0.69 ,$0.76 ,$0.76 ,$0.76 ,$0.31 ,$0.50 ,$0.25 ,$0.75 ,$0.62 ,$0.66 ,$0.69
Hoopeston Regional Hlth Center,8980250,acetaminophen 120 mg rectal suppository,45802073230,J3490,250,$0.82 ,$0.82 ,$0.23 ,$0.75 ,$0.57 ,$0.69 ,$0.75 ,$0.75 ,$0.75 ,$0.30 ,$0.49 ,$0.25 ,$0.74 ,$0.62 ,$0.66 ,$0.68
Hoopeston Regional Hlth Center,8980250,calcium citrate 315 mg calcium-vitamin D3 6.25 mcg (250 unit) tablet,46122008176,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,"DULoxetine 20 mg capsule,delayed release",47335038186,,250,$32.62 ,$32.62 ,$9.13 ,$29.85 ,$22.83 ,$27.30 ,$29.85 ,$29.85 ,$29.85 ,$12.02 ,$19.57 ,$9.79 ,$29.36 ,$24.47 ,$26.10 ,$27.07
Hoopeston Regional Hlth Center,8980250,"DULoxetine 30 mg capsule,delayed release",47335038283,,250,$35.60 ,$35.60 ,$9.97 ,$32.57 ,$24.92 ,$29.80 ,$32.57 ,$32.57 ,$32.57 ,$13.12 ,$21.36 ,$10.68 ,$32.04 ,$26.70 ,$28.48 ,$29.55
Hoopeston Regional Hlth Center,8980250,"DULoxetine 60 mg capsule,delayed release",47335038383,,250,$35.60 ,$35.60 ,$9.97 ,$32.57 ,$24.92 ,$29.80 ,$32.57 ,$32.57 ,$32.57 ,$13.12 ,$21.36 ,$10.68 ,$32.04 ,$26.70 ,$28.48 ,$29.55
Hoopeston Regional Hlth Center,8980250,"dilTIAZem ER 300 mg capsule,24 hr,extended release",47335067281,,250,$13.05 ,$13.05 ,$3.65 ,$11.94 ,$9.14 ,$10.92 ,$11.94 ,$11.94 ,$11.94 ,$4.81 ,$7.83 ,$3.92 ,$11.75 ,$9.79 ,$10.44 ,$10.83
Hoopeston Regional Hlth Center,8980250,"desmopressin 10 mcg/spray (0.1 mL) nasal spray (non-refrigerated),DESMOPRESSIN 10 MCG/SPRAY (0.1 ML) NASAL SPRAY",47335078891,,250,"$1,168.50 ","$1,168.50 ",$327.18 ,"$1,069.18 ",$817.95 ,$978.03 ,"$1,069.18 ","$1,069.18 ","$1,069.18 ",$430.59 ,$701.10 ,$350.55 ,"$1,051.65 ",$876.38 ,$934.80 ,$969.86
Hoopeston Regional Hlth Center,8980250,"galantamine ER 8 mg 24 hr capsule,extended release",47335083583,,250,$30.43 ,$30.43 ,$8.52 ,$27.84 ,$21.30 ,$25.47 ,$27.84 ,$27.84 ,$27.84 ,$11.21 ,$18.26 ,$9.13 ,$27.39 ,$22.82 ,$24.34 ,$25.26
Hoopeston Regional Hlth Center,8980250,nitroglycerin 0.1 mg/hr transdermal 24 hour patch,47781029603,,250,$14.24 ,$14.24 ,$3.99 ,$13.03 ,$9.97 ,$11.92 ,$13.03 ,$13.03 ,$13.03 ,$5.25 ,$8.54 ,$4.27 ,$12.82 ,$10.68 ,$11.39 ,$11.82
Hoopeston Regional Hlth Center,8980250,nitroglycerin 0.2 mg/hr transdermal 24 hour patch,47781029703,,250,$14.43 ,$14.43 ,$4.04 ,$13.20 ,$10.10 ,$12.08 ,$13.20 ,$13.20 ,$13.20 ,$5.32 ,$8.66 ,$4.33 ,$12.99 ,$10.82 ,$11.54 ,$11.98
Hoopeston Regional Hlth Center,8980250,metoprolol tartrate 5 mg/5 mL intravenous solution,47781058717,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,"EPINEPHrine (Jr) 0.15 mg/0.3 mL injection,auto-injector",49502010102,J3490,250,$778.39 ,$778.39 ,$217.95 ,$712.23 ,$544.87 ,$651.51 ,$712.23 ,$712.23 ,$712.23 ,$286.84 ,$467.03 ,$233.52 ,$700.55 ,$583.79 ,$622.71 ,$646.06
Hoopeston Regional Hlth Center,8980250,"EPINEPHrine 0.3 mg/0.3 mL injection, auto-injector",49502010202,J3490,250,$778.39 ,$778.39 ,$217.95 ,$712.23 ,$544.87 ,$651.51 ,$712.23 ,$712.23 ,$712.23 ,$286.84 ,$467.03 ,$233.52 ,$700.55 ,$583.79 ,$622.71 ,$646.06
Hoopeston Regional Hlth Center,8980250,lamiVUDine 150 mg tablet,49702020318,,250,$37.25 ,$37.25 ,$10.43 ,$34.08 ,$26.08 ,$31.18 ,$34.08 ,$34.08 ,$34.08 ,$13.73 ,$22.35 ,$11.18 ,$33.53 ,$27.94 ,$29.80 ,$30.92
Hoopeston Regional Hlth Center,8980250,lamiVUDine 10 mg/mL oral solution,49702020548,,250,$55.35 ,$55.35 ,$15.50 ,$50.65 ,$38.75 ,$46.33 ,$50.65 ,$50.65 ,$50.65 ,$20.40 ,$33.21 ,$16.61 ,$49.82 ,$41.51 ,$44.28 ,$45.94
Hoopeston Regional Hlth Center,8980250,fosamprenavir 700 mg tablet,49702020718,,250,$89.25 ,$89.25 ,$24.99 ,$81.66 ,$62.48 ,$74.70 ,$81.66 ,$81.66 ,$81.66 ,$32.89 ,$53.55 ,$26.78 ,$80.33 ,$66.94 ,$71.40 ,$74.08
Hoopeston Regional Hlth Center,8980250,glycopyrrolate 1 mg tablet,49884006501,,250,$8.45 ,$8.45 ,$2.37 ,$7.73 ,$5.92 ,$7.07 ,$7.73 ,$7.73 ,$7.73 ,$3.11 ,$5.07 ,$2.54 ,$7.61 ,$6.34 ,$6.76 ,$7.01
Hoopeston Regional Hlth Center,8980250,"propafenone ER 325 mg capsule,extended release 12 hr",49884021002,,250,$43.15 ,$43.15 ,$12.08 ,$39.48 ,$30.21 ,$36.12 ,$39.48 ,$39.48 ,$39.48 ,$15.90 ,$25.89 ,$12.95 ,$38.84 ,$32.36 ,$34.52 ,$35.81
Hoopeston Regional Hlth Center,8980250,"propafenone ER 425 mg capsule,extended release 12 hr",49884021102,,250,$43.15 ,$43.15 ,$12.08 ,$39.48 ,$30.21 ,$36.12 ,$39.48 ,$39.48 ,$39.48 ,$15.90 ,$25.89 ,$12.95 ,$38.84 ,$32.36 ,$34.52 ,$35.81
Hoopeston Regional Hlth Center,8980250,doxepin 25 mg capsule,49884021801,,250,$6.16 ,$6.16 ,$1.72 ,$5.64 ,$4.31 ,$5.16 ,$5.64 ,$5.64 ,$5.64 ,$2.27 ,$3.70 ,$1.85 ,$5.54 ,$4.62 ,$4.93 ,$5.11
Hoopeston Regional Hlth Center,8980250,minoxidiL 2.5 mg tablet,49884025601,,250,$5.97 ,$5.97 ,$1.67 ,$5.46 ,$4.18 ,$5.00 ,$5.46 ,$5.46 ,$5.46 ,$2.20 ,$3.58 ,$1.79 ,$5.37 ,$4.48 ,$4.78 ,$4.96
Hoopeston Regional Hlth Center,8980250,clonazePAM 0.25 mg disintegrating tablet,49884030702,,250,$10.71 ,$10.71 ,$3.00 ,$9.80 ,$7.50 ,$8.96 ,$9.80 ,$9.80 ,$9.80 ,$3.95 ,$6.43 ,$3.21 ,$9.64 ,$8.03 ,$8.57 ,$8.89
Hoopeston Regional Hlth Center,8980250,zafirlukast 20 mg tablet,49884055402,,250,$11.87 ,$11.87 ,$3.32 ,$10.86 ,$8.31 ,$9.94 ,$10.86 ,$10.86 ,$10.86 ,$4.37 ,$7.12 ,$3.56 ,$10.68 ,$8.90 ,$9.50 ,$9.85
Hoopeston Regional Hlth Center,8980250,methIMAzole 10 mg tablet,49884064101,,250,$5.91 ,$5.91 ,$1.65 ,$5.41 ,$4.14 ,$4.95 ,$5.41 ,$5.41 ,$5.41 ,$2.18 ,$3.55 ,$1.77 ,$5.32 ,$4.43 ,$4.73 ,$4.91
Hoopeston Regional Hlth Center,8980250,"Lactobacillus reuteri 100 million cell/5 drop oral drops,suspension",50000093560,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,ulipristaL 30 mg tablet,50102091101,,250,$158.30 ,$158.30 ,$44.32 ,$144.84 ,$110.81 ,$132.50 ,$144.84 ,$144.84 ,$144.84 ,$58.33 ,$94.98 ,$47.49 ,$142.47 ,$118.73 ,$126.64 ,$131.39
Hoopeston Regional Hlth Center,8980250,metroNIDAZOLE 250 mg tablet,50111033301,,250,$4.35 ,$4.35 ,$1.22 ,$3.98 ,$3.05 ,$3.64 ,$3.98 ,$3.98 ,$3.98 ,$1.60 ,$2.61 ,$1.31 ,$3.92 ,$3.26 ,$3.48 ,$3.61
Hoopeston Regional Hlth Center,8980250,metroNIDAZOLE 500 mg tablet,50111033401,,250,$5.72 ,$5.72 ,$1.60 ,$5.23 ,$4.00 ,$4.79 ,$5.23 ,$5.23 ,$5.23 ,$2.11 ,$3.43 ,$1.72 ,$5.15 ,$4.29 ,$4.58 ,$4.75
Hoopeston Regional Hlth Center,8980250,hydrALAZINE 10 mg tablet,50111039801,,250,$4.25 ,$4.25 ,$1.19 ,$3.89 ,$2.98 ,$3.56 ,$3.89 ,$3.89 ,$3.89 ,$1.57 ,$2.55 ,$1.28 ,$3.83 ,$3.19 ,$3.40 ,$3.53
Hoopeston Regional Hlth Center,8980250,FLUoxetine 20 mg capsule,50111064801,,250,$14.76 ,$14.76 ,$4.13 ,$13.51 ,$10.33 ,$12.35 ,$13.51 ,$13.51 ,$13.51 ,$5.44 ,$8.86 ,$4.43 ,$13.28 ,$11.07 ,$11.81 ,$12.25
Hoopeston Regional Hlth Center,8980250,azithromycin 250 mg tablet,50111078710,,250,$35.39 ,$35.39 ,$9.91 ,$32.38 ,$24.77 ,$29.62 ,$32.38 ,$32.38 ,$32.38 ,$13.04 ,$21.23 ,$10.62 ,$31.85 ,$26.54 ,$28.31 ,$29.37
Hoopeston Regional Hlth Center,8980250,metFORMIN 500 mg tablet,50228010501,,250,$5.62 ,$5.62 ,$1.57 ,$5.14 ,$3.93 ,$4.70 ,$5.14 ,$5.14 ,$5.14 ,$2.07 ,$3.37 ,$1.69 ,$5.06 ,$4.22 ,$4.50 ,$4.66
Hoopeston Regional Hlth Center,8980250,carisoprodoL 350 mg tablet,50228010901,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,"witch hazel 50 % topical pads,glycerin-witch hazel 12.5 %-50 % topical pads",50289325001,,250,$155.13 ,$155.13 ,$43.44 ,$141.94 ,$108.59 ,$129.84 ,$141.94 ,$141.94 ,$141.94 ,$57.17 ,$93.08 ,$46.54 ,$139.62 ,$116.35 ,$124.10 ,$128.76
Hoopeston Regional Hlth Center,8980250,phenylephrine 0.25 % nasal spray,50323000602,,250,$25.59 ,$25.59 ,$7.17 ,$23.41 ,$17.91 ,$21.42 ,$23.41 ,$23.41 ,$23.41 ,$9.43 ,$15.35 ,$7.68 ,$23.03 ,$19.19 ,$20.47 ,$21.24
Hoopeston Regional Hlth Center,8980250,levETIRAcetam 100 mg/mL oral solution,50383024116,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,ferrous sulfate 15 mg iron (75 mg)/mL oral drops,50383062750,,250,$59.08 ,$59.08 ,$16.54 ,$54.06 ,$41.36 ,$49.45 ,$54.06 ,$54.06 ,$54.06 ,$21.77 ,$35.45 ,$17.72 ,$53.17 ,$44.31 ,$47.26 ,$49.04
Hoopeston Regional Hlth Center,8980250,albuterol sulfate 2 mg/5 mL oral syrup,50383074016,,250,$10.66 ,$10.66 ,$2.98 ,$9.75 ,$7.46 ,$8.92 ,$9.75 ,$9.75 ,$9.75 ,$3.93 ,$6.40 ,$3.20 ,$9.59 ,$8.00 ,$8.53 ,$8.85
Hoopeston Regional Hlth Center,8980250,Lidocaine 2 % Mucosal Soln,50383077515,,250,$7.36 ,$7.36 ,$2.06 ,$6.73 ,$5.15 ,$6.16 ,$6.73 ,$6.73 ,$6.73 ,$2.71 ,$4.42 ,$2.21 ,$6.62 ,$5.52 ,$5.89 ,$6.11
Hoopeston Regional Hlth Center,8980250,Lidocaine 2 % Mucosal Soln,50383077517,,250,$7.36 ,$7.36 ,$2.06 ,$6.73 ,$5.15 ,$6.16 ,$6.73 ,$6.73 ,$6.73 ,$2.71 ,$4.42 ,$2.21 ,$6.62 ,$5.52 ,$5.89 ,$6.11
Hoopeston Regional Hlth Center,8980250,estradioL 0.075 mg/24 hr weekly transdermal patch,50419045304,,250,$160.73 ,$160.73 ,$45.00 ,$147.07 ,$112.51 ,$134.53 ,$147.07 ,$147.07 ,$147.07 ,$59.23 ,$96.44 ,$48.22 ,$144.66 ,$120.55 ,$128.58 ,$133.41
Hoopeston Regional Hlth Center,8980250,estradioL 0.025 mg/24 hr weekly transdermal patch,50419045404,,250,$160.73 ,$160.73 ,$45.00 ,$147.07 ,$112.51 ,$134.53 ,$147.07 ,$147.07 ,$147.07 ,$59.23 ,$96.44 ,$48.22 ,$144.66 ,$120.55 ,$128.58 ,$133.41
Hoopeston Regional Hlth Center,8980250,estradioL 0.0375 mg/24 hr weekly transdermal patch,50419045604,,250,$160.73 ,$160.73 ,$45.00 ,$147.07 ,$112.51 ,$134.53 ,$147.07 ,$147.07 ,$147.07 ,$59.23 ,$96.44 ,$48.22 ,$144.66 ,$120.55 ,$128.58 ,$133.41
Hoopeston Regional Hlth Center,8980250,itraconazole 10 mg/mL oral solution,50458029515,,250,$166.57 ,$166.57 ,$46.64 ,$152.41 ,$116.60 ,$139.42 ,$152.41 ,$152.41 ,$152.41 ,$61.38 ,$99.94 ,$49.97 ,$149.91 ,$124.93 ,$133.26 ,$138.25
Hoopeston Regional Hlth Center,8980250,rivaroxaban 2.5 mg tablet,50458057710,,250,$42.63 ,$42.63 ,$11.94 ,$39.01 ,$29.84 ,$35.68 ,$39.01 ,$39.01 ,$39.01 ,$15.71 ,$25.58 ,$12.79 ,$38.37 ,$31.97 ,$34.10 ,$35.38
Hoopeston Regional Hlth Center,8980250,rivaroxaban 10 mg tablet,50458058010,,250,$77.10 ,$77.10 ,$21.59 ,$70.55 ,$53.97 ,$64.53 ,$70.55 ,$70.55 ,$70.55 ,$28.41 ,$46.26 ,$23.13 ,$69.39 ,$57.83 ,$61.68 ,$63.99
Hoopeston Regional Hlth Center,8980250,levoFLOXacin 750 mg tablet,50458093020,,250,$244.37 ,$244.37 ,$68.42 ,$223.60 ,$171.06 ,$204.54 ,$223.60 ,$223.60 ,$223.60 ,$90.05 ,$146.62 ,$73.31 ,$219.93 ,$183.28 ,$195.50 ,$202.83
Hoopeston Regional Hlth Center,8980250,collagenase clostridium histolyticum 250 unit/gram topical ointment,50484001030,,250,"$1,481.60 ","$1,481.60 ",$414.85 ,"$1,355.66 ","$1,037.12 ","$1,240.10 ","$1,355.66 ","$1,355.66 ","$1,355.66 ",$545.97 ,$888.96 ,$444.48 ,"$1,333.44 ","$1,111.20 ","$1,185.28 ","$1,229.73 "
Hoopeston Regional Hlth Center,8980250,zinc oxide 30.6 % topical cream,50484032400,,250,$104.14 ,$104.14 ,$29.16 ,$95.29 ,$72.90 ,$87.17 ,$95.29 ,$95.29 ,$95.29 ,$38.38 ,$62.48 ,$31.24 ,$93.73 ,$78.11 ,$83.31 ,$86.44
Hoopeston Regional Hlth Center,8980250,diphenhydrAMINE 12.5 mg/5 mL oral liquid,50580053408,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,cyproheptadine 4 mg tablet,50742019001,,250,$7.30 ,$7.30 ,$2.04 ,$6.68 ,$5.11 ,$6.11 ,$6.68 ,$6.68 ,$6.68 ,$2.69 ,$4.38 ,$2.19 ,$6.57 ,$5.48 ,$5.84 ,$6.06
Hoopeston Regional Hlth Center,8980250,"acetaZOLAMIDE ER 500 mg capsule,extended release",50742023301,,250,$22.34 ,$22.34 ,$6.26 ,$20.44 ,$15.64 ,$18.70 ,$20.44 ,$20.44 ,$20.44 ,$8.23 ,$13.40 ,$6.70 ,$20.11 ,$16.76 ,$17.87 ,$18.54
Hoopeston Regional Hlth Center,8980250,"NIFEdipine ER 60 mg tablet,extended release",50742062101,,250,$13.90 ,$13.90 ,$3.89 ,$12.72 ,$9.73 ,$11.63 ,$12.72 ,$12.72 ,$12.72 ,$5.12 ,$8.34 ,$4.17 ,$12.51 ,$10.43 ,$11.12 ,$11.54
Hoopeston Regional Hlth Center,8980250,metOLazone 5 mg tablet,51079002401,,250,$19.73 ,$19.73 ,$5.52 ,$18.05 ,$13.81 ,$16.51 ,$18.05 ,$18.05 ,$18.05 ,$7.27 ,$11.84 ,$5.92 ,$17.76 ,$14.80 ,$15.78 ,$16.38
Hoopeston Regional Hlth Center,8980250,isoniazid 300 mg tablet,51079008320,,250,$8.33 ,$8.33 ,$2.33 ,$7.62 ,$5.83 ,$6.97 ,$7.62 ,$7.62 ,$7.62 ,$3.07 ,$5.00 ,$2.50 ,$7.50 ,$6.25 ,$6.66 ,$6.91
Hoopeston Regional Hlth Center,8980250,amitriptyline 25 mg tablet,51079010720,,250,$5.29 ,$5.29 ,$1.48 ,$4.84 ,$3.70 ,$4.43 ,$4.84 ,$4.84 ,$4.84 ,$1.95 ,$3.17 ,$1.59 ,$4.76 ,$3.97 ,$4.23 ,$4.39
Hoopeston Regional Hlth Center,8980250,dicyclomine 10 mg capsule,51079011820,,250,$5.11 ,$5.11 ,$1.43 ,$4.68 ,$3.58 ,$4.28 ,$4.68 ,$4.68 ,$4.68 ,$1.88 ,$3.07 ,$1.53 ,$4.60 ,$3.83 ,$4.09 ,$4.24
Hoopeston Regional Hlth Center,8980250,dicyclomine 20 mg tablet,51079011920,,250,$5.11 ,$5.11 ,$1.43 ,$4.68 ,$3.58 ,$4.28 ,$4.68 ,$4.68 ,$4.68 ,$1.88 ,$3.07 ,$1.53 ,$4.60 ,$3.83 ,$4.09 ,$4.24
Hoopeston Regional Hlth Center,8980250,amitriptyline 10 mg tablet,51079013120,,250,$3.81 ,$3.81 ,$1.07 ,$3.49 ,$2.67 ,$3.19 ,$3.49 ,$3.49 ,$3.49 ,$1.40 ,$2.29 ,$1.14 ,$3.43 ,$2.86 ,$3.05 ,$3.16
Hoopeston Regional Hlth Center,8980250,chlordiazePOXIDE 25 mg capsule,51079014120,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,amitriptyline 75 mg tablet,51079014720,,250,$11.22 ,$11.22 ,$3.14 ,$10.27 ,$7.85 ,$9.39 ,$10.27 ,$10.27 ,$10.27 ,$4.13 ,$6.73 ,$3.37 ,$10.10 ,$8.42 ,$8.98 ,$9.31
Hoopeston Regional Hlth Center,8980250,methyldopa 500 mg tablet,51079020120,,250,$5.47 ,$5.47 ,$1.53 ,$5.01 ,$3.83 ,$4.58 ,$5.01 ,$5.01 ,$5.01 ,$2.02 ,$3.28 ,$1.64 ,$4.92 ,$4.10 ,$4.38 ,$4.54
Hoopeston Regional Hlth Center,8980250,atorvastatin 40 mg tablet,51079021001,,250,$4.78 ,$4.78 ,$1.34 ,$4.37 ,$3.35 ,$4.00 ,$4.37 ,$4.37 ,$4.37 ,$1.76 ,$2.87 ,$1.43 ,$4.30 ,$3.59 ,$3.82 ,$3.97
Hoopeston Regional Hlth Center,8980250,atorvastatin 40 mg tablet,51079021020,,250,$4.78 ,$4.78 ,$1.34 ,$4.37 ,$3.35 ,$4.00 ,$4.37 ,$4.37 ,$4.37 ,$1.76 ,$2.87 ,$1.43 ,$4.30 ,$3.59 ,$3.82 ,$3.97
Hoopeston Regional Hlth Center,8980250,atorvastatin 80 mg tablet,51079021103,,250,$11.29 ,$11.29 ,$3.16 ,$10.33 ,$7.90 ,$9.45 ,$10.33 ,$10.33 ,$10.33 ,$4.16 ,$6.77 ,$3.39 ,$10.16 ,$8.47 ,$9.03 ,$9.37
Hoopeston Regional Hlth Center,8980250,diazePAM 2 mg tablet,51079028420,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,chlordiazePOXIDE 5 mg capsule,51079037420,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,chlordiazePOXIDE 10 mg capsule,51079037520,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,carBAMazepine 200 mg tablet,51079038520,,250,$9.78 ,$9.78 ,$2.74 ,$8.95 ,$6.85 ,$8.19 ,$8.95 ,$8.95 ,$8.95 ,$3.60 ,$5.87 ,$2.93 ,$8.80 ,$7.34 ,$7.82 ,$8.12
Hoopeston Regional Hlth Center,8980250,doxepin 50 mg capsule,51079043820,,250,$7.77 ,$7.77 ,$2.18 ,$7.11 ,$5.44 ,$6.50 ,$7.11 ,$7.11 ,$7.11 ,$2.86 ,$4.66 ,$2.33 ,$6.99 ,$5.83 ,$6.22 ,$6.45
Hoopeston Regional Hlth Center,8980250,fluPHENAZine 2.5 mg tablet,51079048620,,250,$5.54 ,$5.54 ,$1.55 ,$5.07 ,$3.88 ,$4.64 ,$5.07 ,$5.07 ,$5.07 ,$2.04 ,$3.32 ,$1.66 ,$4.99 ,$4.16 ,$4.43 ,$4.60
Hoopeston Regional Hlth Center,8980250,fluPHENAZine 5 mg tablet,51079048701,,250,$6.06 ,$6.06 ,$1.70 ,$5.54 ,$4.24 ,$5.07 ,$5.54 ,$5.54 ,$5.54 ,$2.23 ,$3.64 ,$1.82 ,$5.45 ,$4.55 ,$4.85 ,$5.03
Hoopeston Regional Hlth Center,8980250,thioridazine 25 mg tablet,51079056620,,250,$5.88 ,$5.88 ,$1.65 ,$5.38 ,$4.12 ,$4.92 ,$5.38 ,$5.38 ,$5.38 ,$2.17 ,$3.53 ,$1.76 ,$5.29 ,$4.41 ,$4.70 ,$4.88
Hoopeston Regional Hlth Center,8980250,thioridazine 100 mg tablet,51079058020,,250,$7.39 ,$7.39 ,$2.07 ,$6.76 ,$5.17 ,$6.19 ,$6.76 ,$6.76 ,$6.76 ,$2.72 ,$4.43 ,$2.22 ,$6.65 ,$5.54 ,$5.91 ,$6.13
Hoopeston Regional Hlth Center,8980250,mafenide 85 mg/g topical cream,51079062383,,250,"$2,350.35 ","$2,350.35 ",$658.10 ,"$2,150.57 ","$1,645.25 ","$1,967.24 ","$2,150.57 ","$2,150.57 ","$2,150.57 ",$866.10 ,"$1,410.21 ",$705.11 ,"$2,115.32 ","$1,762.76 ","$1,880.28 ","$1,950.79 "
Hoopeston Regional Hlth Center,8980250,prazosin 1 mg capsule,51079063020,,250,$10.77 ,$10.77 ,$3.02 ,$9.85 ,$7.54 ,$9.01 ,$9.85 ,$9.85 ,$9.85 ,$3.97 ,$6.46 ,$3.23 ,$9.69 ,$8.08 ,$8.62 ,$8.94
Hoopeston Regional Hlth Center,8980250,prazosin 2 mg capsule,51079063120,,250,$14.09 ,$14.09 ,$3.95 ,$12.89 ,$9.86 ,$11.79 ,$12.89 ,$12.89 ,$12.89 ,$5.19 ,$8.45 ,$4.23 ,$12.68 ,$10.57 ,$11.27 ,$11.69
Hoopeston Regional Hlth Center,8980250,haloperidoL 1 mg tablet,51079073420,,250,$4.62 ,$4.62 ,$1.29 ,$4.23 ,$3.23 ,$3.87 ,$4.23 ,$4.23 ,$4.23 ,$1.70 ,$2.77 ,$1.39 ,$4.16 ,$3.47 ,$3.70 ,$3.83
Hoopeston Regional Hlth Center,8980250,dilTIAZem 30 mg tablet,51079074520,,250,$4.42 ,$4.42 ,$1.24 ,$4.04 ,$3.09 ,$3.70 ,$4.04 ,$4.04 ,$4.04 ,$1.63 ,$2.65 ,$1.33 ,$3.98 ,$3.32 ,$3.54 ,$3.67
Hoopeston Regional Hlth Center,8980250,HYDROcodone 10 mg-acetaminophen 325 mg tablet,51079077920,,250,$9.79 ,$9.79 ,$2.74 ,$8.96 ,$6.85 ,$8.19 ,$8.96 ,$8.96 ,$8.96 ,$3.61 ,$5.87 ,$2.94 ,$8.81 ,$7.34 ,$7.83 ,$8.13
Hoopeston Regional Hlth Center,8980250,ALPRAZolam 0.5 mg tablet,51079078920,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,nadoloL 40 mg tablet,51079081320,,250,$33.44 ,$33.44 ,$9.36 ,$30.60 ,$23.41 ,$27.99 ,$30.60 ,$30.60 ,$30.60 ,$12.32 ,$20.06 ,$10.03 ,$30.10 ,$25.08 ,$26.75 ,$27.76
Hoopeston Regional Hlth Center,8980250,carBAMazepine 100 mg chewable tablet,51079087020,,250,$5.40 ,$5.40 ,$1.51 ,$4.94 ,$3.78 ,$4.52 ,$4.94 ,$4.94 ,$4.94 ,$1.99 ,$3.24 ,$1.62 ,$4.86 ,$4.05 ,$4.32 ,$4.48
Hoopeston Regional Hlth Center,8980250,clonazePAM 1 mg tablet,51079088220,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,"verapamiL ER 120 mg 24 hr capsule,extended release",51079091720,,250,$26.93 ,$26.93 ,$7.54 ,$24.64 ,$18.85 ,$22.54 ,$24.64 ,$24.64 ,$24.64 ,$9.92 ,$16.16 ,$8.08 ,$24.24 ,$20.20 ,$21.54 ,$22.35
Hoopeston Regional Hlth Center,8980250,buPROPion HCL 75 mg tablet,51079094320,,250,$9.54 ,$9.54 ,$2.67 ,$8.73 ,$6.68 ,$7.98 ,$8.73 ,$8.73 ,$8.73 ,$3.52 ,$5.72 ,$2.86 ,$8.59 ,$7.16 ,$7.63 ,$7.92
Hoopeston Regional Hlth Center,8980250,buPROPion HCL 100 mg tablet,51079094420,,250,$11.48 ,$11.48 ,$3.21 ,$10.50 ,$8.04 ,$9.61 ,$10.50 ,$10.50 ,$10.50 ,$4.23 ,$6.89 ,$3.44 ,$10.33 ,$8.61 ,$9.18 ,$9.53
Hoopeston Regional Hlth Center,8980250,doxazosin 4 mg tablet,51079095920,,250,$20.71 ,$20.71 ,$5.80 ,$18.95 ,$14.50 ,$17.33 ,$18.95 ,$18.95 ,$18.95 ,$7.63 ,$12.43 ,$6.21 ,$18.64 ,$15.53 ,$16.57 ,$17.19
Hoopeston Regional Hlth Center,8980250,busPIRone 5 mg tablet,51079098520,,250,$5.92 ,$5.92 ,$1.66 ,$5.42 ,$4.14 ,$4.96 ,$5.42 ,$5.42 ,$5.42 ,$2.18 ,$3.55 ,$1.78 ,$5.33 ,$4.44 ,$4.74 ,$4.91
Hoopeston Regional Hlth Center,8980250,phenazopyridine 200 mg tablet,51293081101,,250,$20.97 ,$20.97 ,$5.87 ,$19.19 ,$14.68 ,$17.55 ,$19.19 ,$19.19 ,$19.19 ,$7.73 ,$12.58 ,$6.29 ,$18.87 ,$15.73 ,$16.78 ,$17.41
Hoopeston Regional Hlth Center,8980250,hyoscyamine 0.125 mg sublingual tablet,51525011301,,250,$4.95 ,$4.95 ,$1.39 ,$4.53 ,$3.47 ,$4.14 ,$4.53 ,$4.53 ,$4.53 ,$1.82 ,$2.97 ,$1.49 ,$4.46 ,$3.71 ,$3.96 ,$4.11
Hoopeston Regional Hlth Center,8980250,felbamate 600 mg tablet,51525043101,,250,$28.88 ,$28.88 ,$8.09 ,$26.43 ,$20.22 ,$24.17 ,$26.43 ,$26.43 ,$26.43 ,$10.64 ,$17.33 ,$8.66 ,$25.99 ,$21.66 ,$23.10 ,$23.97
Hoopeston Regional Hlth Center,8980250,sennosides 8.6 mg-docusate sodium 50 mg tablet,51645085099,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,sennosides 8.6 mg tablet,51645085110,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,cyanocobalamin (vit B-12) 500 mcg tablet,51645091301,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,folic acid 400 mcg tablet,51645093201,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,loratadine 10 mg tablet,51660052601,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,desonide 0.05 % topical cream,51672128001,,250,$395.14 ,$395.14 ,$110.64 ,$361.55 ,$276.60 ,$330.73 ,$361.55 ,$361.55 ,$361.55 ,$145.61 ,$237.08 ,$118.54 ,$355.63 ,$296.36 ,$316.11 ,$327.97
Hoopeston Regional Hlth Center,8980250,clotrimazole 2 % vaginal cream,51672206200,,250,$72.18 ,$72.18 ,$20.21 ,$66.04 ,$50.53 ,$60.41 ,$66.04 ,$66.04 ,$66.04 ,$26.60 ,$43.31 ,$21.65 ,$64.96 ,$54.14 ,$57.74 ,$59.91
Hoopeston Regional Hlth Center,8980250,loratadine 5 mg/5 mL oral solution,51672207308,J3490,250,$9.38 ,$9.38 ,$2.63 ,$8.58 ,$6.57 ,$7.85 ,$8.58 ,$8.58 ,$8.58 ,$3.46 ,$5.63 ,$2.81 ,$8.44 ,$7.04 ,$7.50 ,$7.79
Hoopeston Regional Hlth Center,8980250,acetaminophen 325 mg rectal suppository,51672211602,,250,$1.12 ,$1.12 ,$0.31 ,$1.02 ,$0.78 ,$0.94 ,$1.02 ,$1.02 ,$1.02 ,$0.41 ,$0.67 ,$0.34 ,$1.01 ,$0.84 ,$0.90 ,$0.93
Hoopeston Regional Hlth Center,8980250,nortriptyline 10 mg capsule,51672400101,,250,$5.76 ,$5.76 ,$1.61 ,$5.27 ,$4.03 ,$4.82 ,$5.27 ,$5.27 ,$5.27 ,$2.12 ,$3.46 ,$1.73 ,$5.18 ,$4.32 ,$4.61 ,$4.78
Hoopeston Regional Hlth Center,8980250,nortriptyline 25 mg capsule,51672400201,,250,$9.17 ,$9.17 ,$2.57 ,$8.39 ,$6.42 ,$7.68 ,$8.39 ,$8.39 ,$8.39 ,$3.38 ,$5.50 ,$2.75 ,$8.25 ,$6.88 ,$7.34 ,$7.61
Hoopeston Regional Hlth Center,8980250,nortriptyline 50 mg capsule,51672400301,,250,$15.22 ,$15.22 ,$4.26 ,$13.93 ,$10.65 ,$12.74 ,$13.93 ,$13.93 ,$13.93 ,$5.61 ,$9.13 ,$4.57 ,$13.70 ,$11.42 ,$12.18 ,$12.63
Hoopeston Regional Hlth Center,8980250,etodolac 200 mg capsule,51672401601,,250,$9.03 ,$9.03 ,$2.53 ,$8.26 ,$6.32 ,$7.56 ,$8.26 ,$8.26 ,$8.26 ,$3.33 ,$5.42 ,$2.71 ,$8.13 ,$6.77 ,$7.22 ,$7.49
Hoopeston Regional Hlth Center,8980250,etodolac 300 mg capsule,51672401701,,250,$9.87 ,$9.87 ,$2.76 ,$9.03 ,$6.91 ,$8.26 ,$9.03 ,$9.03 ,$9.03 ,$3.64 ,$5.92 ,$2.96 ,$8.88 ,$7.40 ,$7.90 ,$8.19
Hoopeston Regional Hlth Center,8980250,enalapril maleate 2.5 mg tablet,51672403701,,250,$9.12 ,$9.12 ,$2.55 ,$8.34 ,$6.38 ,$7.63 ,$8.34 ,$8.34 ,$8.34 ,$3.36 ,$5.47 ,$2.74 ,$8.21 ,$6.84 ,$7.30 ,$7.57
Hoopeston Regional Hlth Center,8980250,enalapril maleate 5 mg tablet,51672403801,,250,$10.96 ,$10.96 ,$3.07 ,$10.03 ,$7.67 ,$9.17 ,$10.03 ,$10.03 ,$10.03 ,$4.04 ,$6.58 ,$3.29 ,$9.86 ,$8.22 ,$8.77 ,$9.10
Hoopeston Regional Hlth Center,8980250,enalapril maleate 10 mg tablet,51672403901,,250,$11.39 ,$11.39 ,$3.19 ,$10.42 ,$7.97 ,$9.53 ,$10.42 ,$10.42 ,$10.42 ,$4.20 ,$6.83 ,$3.42 ,$10.25 ,$8.54 ,$9.11 ,$9.45
Hoopeston Regional Hlth Center,8980250,clorazepate dipotassium 3.75 mg tablet,51672404201,,250,$21.13 ,$21.13 ,$5.92 ,$19.33 ,$14.79 ,$17.69 ,$19.33 ,$19.33 ,$19.33 ,$7.79 ,$12.68 ,$6.34 ,$19.02 ,$15.85 ,$16.90 ,$17.54
Hoopeston Regional Hlth Center,8980250,phenytoin sodium extended 100 mg capsule,51672411103,,250,$5.31 ,$5.31 ,$1.49 ,$4.86 ,$3.72 ,$4.44 ,$4.86 ,$4.86 ,$4.86 ,$1.96 ,$3.19 ,$1.59 ,$4.78 ,$3.98 ,$4.25 ,$4.41
Hoopeston Regional Hlth Center,8980250,felbamate 600 mg/5 mL oral suspension,51672417201,,250,$53.66 ,$53.66 ,$15.02 ,$49.10 ,$37.56 ,$44.91 ,$49.10 ,$49.10 ,$49.10 ,$19.77 ,$32.20 ,$16.10 ,$48.29 ,$40.25 ,$42.93 ,$44.54
Hoopeston Regional Hlth Center,8980250,dofetilide 250 mcg capsule,51862002560,,250,$38.09 ,$38.09 ,$10.67 ,$34.85 ,$26.66 ,$31.88 ,$34.85 ,$34.85 ,$34.85 ,$14.04 ,$22.85 ,$11.43 ,$34.28 ,$28.57 ,$30.47 ,$31.61
Hoopeston Regional Hlth Center,8980250,diazePAM 5 mg tablet,51862006301,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,fentaNYL 75 mcg/hr transdermal patch,51862031678,,250,$173.21 ,$173.21 ,$48.50 ,$158.49 ,$121.25 ,$144.98 ,$158.49 ,$158.49 ,$158.49 ,$63.83 ,$103.93 ,$51.96 ,$155.89 ,$129.91 ,$138.57 ,$143.76
Hoopeston Regional Hlth Center,8980250,estradioL 1 mg tablet,51862033301,,250,$5.50 ,$5.50 ,$1.54 ,$5.03 ,$3.85 ,$4.60 ,$5.03 ,$5.03 ,$5.03 ,$2.03 ,$3.30 ,$1.65 ,$4.95 ,$4.13 ,$4.40 ,$4.57
Hoopeston Regional Hlth Center,8980250,estradioL 2 mg tablet,51862033401,,250,$6.72 ,$6.72 ,$1.88 ,$6.15 ,$4.70 ,$5.62 ,$6.15 ,$6.15 ,$6.15 ,$2.48 ,$4.03 ,$2.02 ,$6.05 ,$5.04 ,$5.38 ,$5.58
Hoopeston Regional Hlth Center,8980250,cloNIDine 0.1 mg/24 hr weekly transdermal patch,51862045304,,250,$124.20 ,$124.20 ,$34.78 ,$113.64 ,$86.94 ,$103.96 ,$113.64 ,$113.64 ,$113.64 ,$45.77 ,$74.52 ,$37.26 ,$111.78 ,$93.15 ,$99.36 ,$103.09
Hoopeston Regional Hlth Center,8980250,cloNIDine 0.2 mg/24 hr weekly transdermal patch,51862045404,,250,$203.55 ,$203.55 ,$56.99 ,$186.25 ,$142.49 ,$170.37 ,$186.25 ,$186.25 ,$186.25 ,$75.01 ,$122.13 ,$61.07 ,$183.20 ,$152.66 ,$162.84 ,$168.95
Hoopeston Regional Hlth Center,8980250,cloNIDine 0.3 mg/24 hr weekly transdermal patch,51862045504,,250,$279.22 ,$279.22 ,$78.18 ,$255.49 ,$195.45 ,$233.71 ,$255.49 ,$255.49 ,$255.49 ,$102.89 ,$167.53 ,$83.77 ,$251.30 ,$209.42 ,$223.38 ,$231.75
Hoopeston Regional Hlth Center,8980250,fluocinonide 0.05 % topical cream,51862049415,,250,$233.26 ,$233.26 ,$65.31 ,$213.43 ,$163.28 ,$195.24 ,$213.43 ,$213.43 ,$213.43 ,$85.96 ,$139.96 ,$69.98 ,$209.93 ,$174.95 ,$186.61 ,$193.61
Hoopeston Regional Hlth Center,8980250,nevirapine 200 mg tablet,51991033106,,250,$46.09 ,$46.09 ,$12.91 ,$42.17 ,$32.26 ,$38.58 ,$42.17 ,$42.17 ,$42.17 ,$16.98 ,$27.65 ,$13.83 ,$41.48 ,$34.57 ,$36.87 ,$38.25
Hoopeston Regional Hlth Center,8980250,rivastigmine 1.5 mg capsule,51991079306,,250,$24.05 ,$24.05 ,$6.73 ,$22.01 ,$16.84 ,$20.13 ,$22.01 ,$22.01 ,$22.01 ,$8.86 ,$14.43 ,$7.22 ,$21.65 ,$18.04 ,$19.24 ,$19.96
Hoopeston Regional Hlth Center,8980250,"cholecalciferol (vitamin D3) 1,250 mcg (50,000 unit) capsule",53191036201,,250,$3.73 ,$3.73 ,$1.04 ,$3.41 ,$2.61 ,$3.12 ,$3.41 ,$3.41 ,$3.41 ,$1.37 ,$2.24 ,$1.12 ,$3.36 ,$2.80 ,$2.98 ,$3.10
Hoopeston Regional Hlth Center,8980250,"quiNIDine gluconate ER 324 mg tablet,extended release",53489014101,,250,$39.87 ,$39.87 ,$11.16 ,$36.48 ,$27.91 ,$33.37 ,$36.48 ,$36.48 ,$36.48 ,$14.69 ,$23.92 ,$11.96 ,$35.88 ,$29.90 ,$31.90 ,$33.09
Hoopeston Regional Hlth Center,8980250,allopurinoL 100 mg tablet,53489015610,,250,$4.58 ,$4.58 ,$1.28 ,$4.19 ,$3.21 ,$3.83 ,$4.19 ,$4.19 ,$4.19 ,$1.69 ,$2.75 ,$1.37 ,$4.12 ,$3.44 ,$3.66 ,$3.80
Hoopeston Regional Hlth Center,8980250,naproxen 250 mg tablet,53746018801,,250,$5.93 ,$5.93 ,$1.66 ,$5.43 ,$4.15 ,$4.96 ,$5.43 ,$5.43 ,$5.43 ,$2.19 ,$3.56 ,$1.78 ,$5.34 ,$4.45 ,$4.74 ,$4.92
Hoopeston Regional Hlth Center,8980250,"mesalamine CR 250 mg capsule,controlled release",54092018981,,250,$19.31 ,$19.31 ,$5.41 ,$17.67 ,$13.52 ,$16.16 ,$17.67 ,$17.67 ,$17.67 ,$7.12 ,$11.59 ,$5.79 ,$17.38 ,$14.48 ,$15.45 ,$16.03
Hoopeston Regional Hlth Center,8980250,lanthanum 500 mg chewable tablet,54092025290,,250,$58.58 ,$58.58 ,$16.40 ,$53.60 ,$41.01 ,$49.03 ,$53.60 ,$53.60 ,$53.60 ,$21.59 ,$35.15 ,$17.57 ,$52.72 ,$43.94 ,$46.86 ,$48.62
Hoopeston Regional Hlth Center,8980250,sorbitoL 70 % solution,54162070016,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,potassium chloride 20 mEq oral packet,54288012510,,250,$43.85 ,$43.85 ,$12.28 ,$40.12 ,$30.70 ,$36.70 ,$40.12 ,$40.12 ,$40.12 ,$16.16 ,$26.31 ,$13.16 ,$39.47 ,$32.89 ,$35.08 ,$36.40
Hoopeston Regional Hlth Center,8980250,levOCARNitine (with sugar) 100 mg/mL oral solution,54482014508,,250,$252.85 ,$252.85 ,$70.80 ,$231.36 ,$177.00 ,$211.64 ,$231.36 ,$231.36 ,$231.36 ,$93.18 ,$151.71 ,$75.86 ,$227.57 ,$189.64 ,$202.28 ,$209.87
Hoopeston Regional Hlth Center,8980250,"mvi,adult no.4 with vit K 3300 unit-150 mcg/10 mL intravenous solution",54643564901,,250,$111.95 ,$111.95 ,$31.35 ,$102.43 ,$78.37 ,$93.70 ,$102.43 ,$102.43 ,$102.43 ,$41.25 ,$67.17 ,$33.59 ,$100.76 ,$83.96 ,$89.56 ,$92.92
Hoopeston Regional Hlth Center,8980250,homatropine 5 % eye drops,54799043105,,250,$227.64 ,$227.64 ,$63.74 ,$208.29 ,$159.35 ,$190.53 ,$208.29 ,$208.29 ,$208.29 ,$83.89 ,$136.58 ,$68.29 ,$204.88 ,$170.73 ,$182.11 ,$188.94
Hoopeston Regional Hlth Center,8980250,doxepin 10 mg/mL oral concentrate,54838051240,,250,$10.44 ,$10.44 ,$2.92 ,$9.55 ,$7.31 ,$8.74 ,$9.55 ,$9.55 ,$9.55 ,$3.85 ,$6.26 ,$3.13 ,$9.40 ,$7.83 ,$8.35 ,$8.67
Hoopeston Regional Hlth Center,8980250,FLUoxetine 20 mg/5 mL (4 mg/mL) oral solution,54838052340,,250,$24.15 ,$24.15 ,$6.76 ,$22.10 ,$16.91 ,$20.21 ,$22.10 ,$22.10 ,$22.10 ,$8.90 ,$14.49 ,$7.25 ,$21.74 ,$18.11 ,$19.32 ,$20.04
Hoopeston Regional Hlth Center,8980250,fluconazole 200 mg tablet,55111014601,,250,$55.78 ,$55.78 ,$15.62 ,$51.04 ,$39.05 ,$46.69 ,$51.04 ,$51.04 ,$51.04 ,$20.55 ,$33.47 ,$16.73 ,$50.20 ,$41.84 ,$44.62 ,$46.30
Hoopeston Regional Hlth Center,8980250,SUMAtriptan 100 mg tablet,55111029309,,250,$96.14 ,$96.14 ,$26.92 ,$87.97 ,$67.30 ,$80.47 ,$87.97 ,$87.97 ,$87.97 ,$35.43 ,$57.68 ,$28.84 ,$86.53 ,$72.11 ,$76.91 ,$79.80
Hoopeston Regional Hlth Center,8980250,ibuprofen 400 mg tablet,55111068201,,250,$3.29 ,$3.29 ,$0.92 ,$3.01 ,$2.30 ,$2.75 ,$3.01 ,$3.01 ,$3.01 ,$1.21 ,$1.97 ,$0.99 ,$2.96 ,$2.47 ,$2.63 ,$2.73
Hoopeston Regional Hlth Center,8980250,ibuprofen 600 mg tablet,55111068305,,250,$3.45 ,$3.45 ,$0.97 ,$3.16 ,$2.42 ,$2.89 ,$3.16 ,$3.16 ,$3.16 ,$1.27 ,$2.07 ,$1.04 ,$3.11 ,$2.59 ,$2.76 ,$2.86
Hoopeston Regional Hlth Center,8980250,valGANciclovir 450 mg tablet,55111076260,,250,$233.54 ,$233.54 ,$65.39 ,$213.69 ,$163.48 ,$195.47 ,$213.69 ,$213.69 ,$213.69 ,$86.06 ,$140.12 ,$70.06 ,$210.19 ,$175.16 ,$186.83 ,$193.84
Hoopeston Regional Hlth Center,8980250,bupivacaine (PF) 0.25 % (2.5 mg/mL) injection solution,55150016830,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,esmoloL 100 mg/10 mL (10 mg/mL) intravenous solution,55150019410,,250,$54.62 ,$54.62 ,$15.29 ,$49.98 ,$38.23 ,$45.72 ,$49.98 ,$49.98 ,$49.98 ,$20.13 ,$32.77 ,$16.39 ,$49.16 ,$40.97 ,$43.70 ,$45.33
Hoopeston Regional Hlth Center,8980250,esmolol 100 mg/10 mL (10 mg/mL) IV,55150019410,,250,$54.62 ,$54.62 ,$15.29 ,$49.98 ,$38.23 ,$45.72 ,$49.98 ,$49.98 ,$49.98 ,$20.13 ,$32.77 ,$16.39 ,$49.16 ,$40.97 ,$43.70 ,$45.33
Hoopeston Regional Hlth Center,8980250,succimer 100 mg capsule,55292020111,,250,$94.72 ,$94.72 ,$26.52 ,$86.67 ,$66.30 ,$79.28 ,$86.67 ,$86.67 ,$86.67 ,$34.90 ,$56.83 ,$28.42 ,$85.25 ,$71.04 ,$75.78 ,$78.62
Hoopeston Regional Hlth Center,8980250,etomidate 2 mg/mL intravenous solution,55390076210,J3490,250,$80.57 ,$80.57 ,$22.56 ,$73.72 ,$56.40 ,$67.44 ,$73.72 ,$73.72 ,$73.72 ,$29.69 ,$48.34 ,$24.17 ,$72.51 ,$60.43 ,$64.46 ,$66.87
Hoopeston Regional Hlth Center,8980250,penicillin V potassium 250 mg tablet,57237004001,,250,$6.29 ,$6.29 ,$1.76 ,$5.76 ,$4.40 ,$5.26 ,$5.76 ,$5.76 ,$5.76 ,$2.32 ,$3.77 ,$1.89 ,$5.66 ,$4.72 ,$5.03 ,$5.22
Hoopeston Regional Hlth Center,8980250,torsemide 20 mg tablet,57237014001,,250,$6.16 ,$6.16 ,$1.72 ,$5.64 ,$4.31 ,$5.16 ,$5.64 ,$5.64 ,$5.64 ,$2.27 ,$3.70 ,$1.85 ,$5.54 ,$4.62 ,$4.93 ,$5.11
Hoopeston Regional Hlth Center,8980250,fluconazole 10 mg/mL oral suspension,57237014935,,250,$66.70 ,$66.70 ,$18.68 ,$61.03 ,$46.69 ,$55.83 ,$61.03 ,$61.03 ,$61.03 ,$24.58 ,$40.02 ,$20.01 ,$60.03 ,$50.03 ,$53.36 ,$55.36
Hoopeston Regional Hlth Center,8980250,metoprolol tartrate 100 mg tablet,57664016752,,250,$6.06 ,$6.06 ,$1.70 ,$5.54 ,$4.24 ,$5.07 ,$5.54 ,$5.54 ,$5.54 ,$2.23 ,$3.64 ,$1.82 ,$5.45 ,$4.55 ,$4.85 ,$5.03
Hoopeston Regional Hlth Center,8980250,methylphenidate 5 mg tablet,57664022888,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,chlorthalidone 25 mg tablet,57664064888,,250,$7.95 ,$7.95 ,$2.23 ,$7.27 ,$5.57 ,$6.65 ,$7.27 ,$7.27 ,$7.27 ,$2.93 ,$4.77 ,$2.39 ,$7.16 ,$5.96 ,$6.36 ,$6.60
Hoopeston Regional Hlth Center,8980250,acetaminophen 325 mg tablet,57896010110,J3490,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,"peg 400-hypromellose-glycerin 1 %-0.2 %-0.2 % eye drops,dextran 70-hypromellose 0.1 %-0.3 % eye drops,polyvinyl alcohol-povidone 0.5 %-0.6 % eye drops,polyvinyl alcohol 1.4 % eye drops,peg 400-propylene glycol 0.4 %-0.3 % eye drops",57896018405,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,"mesalamine 1,000 mg rectal suppository",58914050156,,250,$170.80 ,$170.80 ,$47.82 ,$156.28 ,$119.56 ,$142.96 ,$156.28 ,$156.28 ,$156.28 ,$62.94 ,$102.48 ,$51.24 ,$153.72 ,$128.10 ,$136.64 ,$141.76
Hoopeston Regional Hlth Center,8980250,"oxyCODONE ER 10 mg tablet,crush resistant,extended release 12 hr",59011041020,,250,$29.62 ,$29.62 ,$8.29 ,$27.10 ,$20.73 ,$24.79 ,$27.10 ,$27.10 ,$27.10 ,$10.91 ,$17.77 ,$8.89 ,$26.66 ,$22.22 ,$23.70 ,$24.58
Hoopeston Regional Hlth Center,8980250,"oxyCODONE ER 20 mg tablet,crush resistant,extended release 12 hr",59011042020,,250,$46.14 ,$46.14 ,$12.92 ,$42.22 ,$32.30 ,$38.62 ,$42.22 ,$42.22 ,$42.22 ,$17.00 ,$27.68 ,$13.84 ,$41.53 ,$34.61 ,$36.91 ,$38.30
Hoopeston Regional Hlth Center,8980250,"oxyCODONE ER 40 mg tablet,crush resistant,extended release 12 hr",59011044020,,250,$71.52 ,$71.52 ,$20.03 ,$65.44 ,$50.06 ,$59.86 ,$65.44 ,$65.44 ,$65.44 ,$26.36 ,$42.91 ,$21.46 ,$64.37 ,$53.64 ,$57.22 ,$59.36
Hoopeston Regional Hlth Center,8980250,phenobarb-hyoscyamn-atropine-scop 16.2 mg-0.1037 mg-0.0194 mg tablet,59212042510,,250,$54.39 ,$54.39 ,$15.23 ,$49.77 ,$38.07 ,$45.52 ,$49.77 ,$49.77 ,$49.77 ,$20.04 ,$32.63 ,$16.32 ,$48.95 ,$40.79 ,$43.51 ,$45.14
Hoopeston Regional Hlth Center,8980250,beclomethasone diprop 40 mcg/actuation HFA breath activated aerosol,59310030240,,250,"$1,137.76 ","$1,137.76 ",$318.57 ,"$1,041.05 ",$796.43 ,$952.31 ,"$1,041.05 ","$1,041.05 ","$1,041.05 ",$419.26 ,$682.66 ,$341.33 ,"$1,023.98 ",$853.32 ,$910.21 ,$944.34
Hoopeston Regional Hlth Center,8980250,albuterol sulfate 90 mcg/actuation breath activated powder inhaler,59310058020,,250,$391.21 ,$391.21 ,$109.54 ,$357.96 ,$273.85 ,$327.44 ,$357.96 ,$357.96 ,$357.96 ,$144.16 ,$234.73 ,$117.36 ,$352.09 ,$293.41 ,$312.97 ,$324.70
Hoopeston Regional Hlth Center,8980250,ferric subsulfate 259 mg/g topical solution,59365606500,,250,$56.39 ,$56.39 ,$15.79 ,$51.60 ,$39.47 ,$47.20 ,$51.60 ,$51.60 ,$51.60 ,$20.78 ,$33.83 ,$16.92 ,$50.75 ,$42.29 ,$45.11 ,$46.80
Hoopeston Regional Hlth Center,8980250,fluorescein 0.25 %-proparacaine 0.5 % eye drops,59390020505,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,fluorescein 0.25 %-benoxinate 0.4 % eye drops,59390021805,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,meclizine 25 mg tablet,59746012106,,250,$4.20 ,$4.20 ,$1.18 ,$3.84 ,$2.94 ,$3.52 ,$3.84 ,$3.84 ,$3.84 ,$1.55 ,$2.52 ,$1.26 ,$3.78 ,$3.15 ,$3.36 ,$3.49
Hoopeston Regional Hlth Center,8980250,spironolactone 25 mg tablet,59746021601,,250,$4.47 ,$4.47 ,$1.25 ,$4.09 ,$3.13 ,$3.74 ,$4.09 ,$4.09 ,$4.09 ,$1.65 ,$2.68 ,$1.34 ,$4.02 ,$3.35 ,$3.58 ,$3.71
Hoopeston Regional Hlth Center,8980250,spironolactone 100 mg tablet,59746021801,,250,$3.66 ,$3.66 ,$1.02 ,$3.35 ,$2.56 ,$3.06 ,$3.35 ,$3.35 ,$3.35 ,$1.35 ,$2.20 ,$1.10 ,$3.29 ,$2.75 ,$2.93 ,$3.04
Hoopeston Regional Hlth Center,8980250,donepeziL 5 mg tablet,59746032990,,250,$38.43 ,$38.43 ,$10.76 ,$35.16 ,$26.90 ,$32.17 ,$35.16 ,$35.16 ,$35.16 ,$14.16 ,$23.06 ,$11.53 ,$34.59 ,$28.82 ,$30.74 ,$31.90
Hoopeston Regional Hlth Center,8980250,terazosin 5 mg capsule,59746038506,,250,$9.81 ,$9.81 ,$2.75 ,$8.98 ,$6.87 ,$8.21 ,$8.98 ,$8.98 ,$8.98 ,$3.61 ,$5.89 ,$2.94 ,$8.83 ,$7.36 ,$7.85 ,$8.14
Hoopeston Regional Hlth Center,8980250,tolterodine 2 mg tablet,59762080002,,250,$18.16 ,$18.16 ,$5.08 ,$16.62 ,$12.71 ,$15.20 ,$16.62 ,$16.62 ,$16.62 ,$6.69 ,$10.90 ,$5.45 ,$16.34 ,$13.62 ,$14.53 ,$15.07
Hoopeston Regional Hlth Center,8980250,linezolid 600 mg tablet,59762130701,,250,$651.01 ,$651.01 ,$182.28 ,$595.67 ,$455.71 ,$544.90 ,$595.67 ,$595.67 ,$595.67 ,$239.90 ,$390.61 ,$195.30 ,$585.91 ,$488.26 ,$520.81 ,$540.34
Hoopeston Regional Hlth Center,8980250,linezolid 100 mg/5 mL oral suspension,59762130801,,250,$166.08 ,$166.08 ,$46.50 ,$151.96 ,$116.26 ,$139.01 ,$151.96 ,$151.96 ,$151.96 ,$61.20 ,$99.65 ,$49.82 ,$149.47 ,$124.56 ,$132.86 ,$137.85
Hoopeston Regional Hlth Center,8980250,azithromycin 200 mg/5 mL oral suspension,59762314001,,250,$210.05 ,$210.05 ,$58.81 ,$192.20 ,$147.04 ,$175.81 ,$192.20 ,$192.20 ,$192.20 ,$77.40 ,$126.03 ,$63.02 ,$189.05 ,$157.54 ,$168.04 ,$174.34
Hoopeston Regional Hlth Center,8980250,triazolam 0.25 mg tablet,59762371803,,250,$21.75 ,$21.75 ,$6.09 ,$19.90 ,$15.23 ,$18.20 ,$19.90 ,$19.90 ,$19.90 ,$8.01 ,$13.05 ,$6.53 ,$19.58 ,$16.31 ,$17.40 ,$18.05
Hoopeston Regional Hlth Center,8980250,medroxyPROGESTERone 10 mg tablet,59762374202,,250,$4.62 ,$4.62 ,$1.29 ,$4.23 ,$3.23 ,$3.87 ,$4.23 ,$4.23 ,$4.23 ,$1.70 ,$2.77 ,$1.39 ,$4.16 ,$3.47 ,$3.70 ,$3.83
Hoopeston Regional Hlth Center,8980250,miSOPROStoL 100 mcg tablet,59762500702,,250,$6.17 ,$6.17 ,$1.73 ,$5.65 ,$4.32 ,$5.16 ,$5.65 ,$5.65 ,$5.65 ,$2.27 ,$3.70 ,$1.85 ,$5.55 ,$4.63 ,$4.94 ,$5.12
Hoopeston Regional Hlth Center,8980250,fluconazole 40 mg/mL oral suspension,59762503001,,250,$111.37 ,$111.37 ,$31.18 ,$101.90 ,$77.96 ,$93.22 ,$101.90 ,$101.90 ,$101.90 ,$41.04 ,$66.82 ,$33.41 ,$100.23 ,$83.53 ,$89.10 ,$92.44
Hoopeston Regional Hlth Center,8980250,"potassium citrate-citric acid 1,100 mg-334 mg/5 mL oral solution",60258000316,,250,$11.53 ,$11.53 ,$3.23 ,$10.55 ,$8.07 ,$9.65 ,$10.55 ,$10.55 ,$10.55 ,$4.25 ,$6.92 ,$3.46 ,$10.38 ,$8.65 ,$9.22 ,$9.57
Hoopeston Regional Hlth Center,8980250,"potassium, sodium phosphates 280 mg-160 mg-250 mg oral powder packet",60258000601,,250,$5.37 ,$5.37 ,$1.50 ,$4.91 ,$3.76 ,$4.49 ,$4.91 ,$4.91 ,$4.91 ,$1.98 ,$3.22 ,$1.61 ,$4.83 ,$4.03 ,$4.30 ,$4.46
Hoopeston Regional Hlth Center,8980250,hydrOXYzine HCL 10 mg/5 mL oral solution,60432015004,,250,$11.82 ,$11.82 ,$3.31 ,$10.82 ,$8.27 ,$9.89 ,$10.82 ,$10.82 ,$10.82 ,$4.36 ,$7.09 ,$3.55 ,$10.64 ,$8.87 ,$9.46 ,$9.81
Hoopeston Regional Hlth Center,8980250,acetic acid 2 % ear solution,60432074115,,250,$207.39 ,$207.39 ,$58.07 ,$189.76 ,$145.17 ,$173.59 ,$189.76 ,$189.76 ,$189.76 ,$76.42 ,$124.43 ,$62.22 ,$186.65 ,$155.54 ,$165.91 ,$172.13
Hoopeston Regional Hlth Center,8980250,etodolac 400 mg tablet,60505004101,,250,$9.15 ,$9.15 ,$2.56 ,$8.37 ,$6.41 ,$7.66 ,$8.37 ,$8.37 ,$8.37 ,$3.37 ,$5.49 ,$2.75 ,$8.24 ,$6.86 ,$7.32 ,$7.59
Hoopeston Regional Hlth Center,8980250,acyclovir 200 mg capsule,60505004206,,250,$6.88 ,$6.88 ,$1.93 ,$6.30 ,$4.82 ,$5.76 ,$6.30 ,$6.30 ,$6.30 ,$2.54 ,$4.13 ,$2.06 ,$6.19 ,$5.16 ,$5.50 ,$5.71
Hoopeston Regional Hlth Center,8980250,sotaloL 80 mg tablet,60505008000,,250,$14.27 ,$14.27 ,$4.00 ,$13.06 ,$9.99 ,$11.94 ,$13.06 ,$13.06 ,$13.06 ,$5.26 ,$8.56 ,$4.28 ,$12.84 ,$10.70 ,$11.42 ,$11.84
Hoopeston Regional Hlth Center,8980250,gabapentin 100 mg capsule,60505011200,,250,$4.90 ,$4.90 ,$1.37 ,$4.48 ,$3.43 ,$4.10 ,$4.48 ,$4.48 ,$4.48 ,$1.81 ,$2.94 ,$1.47 ,$4.41 ,$3.68 ,$3.92 ,$4.07
Hoopeston Regional Hlth Center,8980250,glipiZIDE 5 mg tablet,60505014100,,250,$4.03 ,$4.03 ,$1.13 ,$3.69 ,$2.82 ,$3.37 ,$3.69 ,$3.69 ,$3.69 ,$1.49 ,$2.42 ,$1.21 ,$3.63 ,$3.02 ,$3.22 ,$3.34
Hoopeston Regional Hlth Center,8980250,glipiZIDE 10 mg tablet,60505014200,,250,$5.45 ,$5.45 ,$1.53 ,$4.99 ,$3.82 ,$4.56 ,$4.99 ,$4.99 ,$4.99 ,$2.01 ,$3.27 ,$1.64 ,$4.91 ,$4.09 ,$4.36 ,$4.52
Hoopeston Regional Hlth Center,8980250,PARoxetine 10 mg/5 mL oral suspension,60505040205,,250,$60.42 ,$60.42 ,$16.92 ,$55.28 ,$42.29 ,$50.57 ,$55.28 ,$55.28 ,$55.28 ,$22.26 ,$36.25 ,$18.13 ,$54.38 ,$45.32 ,$48.34 ,$50.15
Hoopeston Regional Hlth Center,8980250,"fluticasone propionate 50 mcg/actuation nasal spray,suspension",60505082901,,250,$418.30 ,$418.30 ,$117.12 ,$382.74 ,$292.81 ,$350.12 ,$382.74 ,$382.74 ,$382.74 ,$154.14 ,$250.98 ,$125.49 ,$376.47 ,$313.73 ,$334.64 ,$347.19
Hoopeston Regional Hlth Center,8980250,leflunomide 10 mg tablet,60505250201,,250,$67.91 ,$67.91 ,$19.01 ,$62.14 ,$47.54 ,$56.84 ,$62.14 ,$62.14 ,$62.14 ,$25.02 ,$40.75 ,$20.37 ,$61.12 ,$50.93 ,$54.33 ,$56.37
Hoopeston Regional Hlth Center,8980250,modafiniL 100 mg tablet,60505252603,,250,$102.81 ,$102.81 ,$28.79 ,$94.07 ,$71.97 ,$86.05 ,$94.07 ,$94.07 ,$94.07 ,$37.89 ,$61.69 ,$30.84 ,$92.53 ,$77.11 ,$82.25 ,$85.33
Hoopeston Regional Hlth Center,8980250,galantamine 4 mg tablet,60505254206,,250,$17.16 ,$17.16 ,$4.80 ,$15.70 ,$12.01 ,$14.36 ,$15.70 ,$15.70 ,$15.70 ,$6.32 ,$10.30 ,$5.15 ,$15.44 ,$12.87 ,$13.73 ,$14.24
Hoopeston Regional Hlth Center,8980250,OLANZapine 10 mg tablet,60505311300,,250,$77.86 ,$77.86 ,$21.80 ,$71.24 ,$54.50 ,$65.17 ,$71.24 ,$71.24 ,$71.24 ,$28.69 ,$46.72 ,$23.36 ,$70.07 ,$58.40 ,$62.29 ,$64.62
Hoopeston Regional Hlth Center,8980250,selegiline 5 mg tablet,60505343803,,250,$12.13 ,$12.13 ,$3.40 ,$11.10 ,$8.49 ,$10.15 ,$11.10 ,$11.10 ,$11.10 ,$4.47 ,$7.28 ,$3.64 ,$10.92 ,$9.10 ,$9.70 ,$10.07
Hoopeston Regional Hlth Center,8980250,celecoxib 100 mg capsule,60505384801,,250,$23.87 ,$23.87 ,$6.68 ,$21.84 ,$16.71 ,$19.98 ,$21.84 ,$21.84 ,$21.84 ,$8.80 ,$14.32 ,$7.16 ,$21.48 ,$17.90 ,$19.10 ,$19.81
Hoopeston Regional Hlth Center,8980250,prasugreL 10 mg tablet,60505464303,,250,$65.92 ,$65.92 ,$18.46 ,$60.32 ,$46.14 ,$55.18 ,$60.32 ,$60.32 ,$60.32 ,$24.29 ,$39.55 ,$19.78 ,$59.33 ,$49.44 ,$52.74 ,$54.71
Hoopeston Regional Hlth Center,8980250,fentaNYL 100 mcg/hr transdermal patch,60505700900,,250,$285.98 ,$285.98 ,$80.07 ,$261.67 ,$200.19 ,$239.37 ,$261.67 ,$261.67 ,$261.67 ,$105.38 ,$171.59 ,$85.79 ,$257.38 ,$214.49 ,$228.78 ,$237.36
Hoopeston Regional Hlth Center,8980250,fentaNYL 100 mcg/hr transdermal patch,60505700902,,250,$285.98 ,$285.98 ,$80.07 ,$261.67 ,$200.19 ,$239.37 ,$261.67 ,$261.67 ,$261.67 ,$105.38 ,$171.59 ,$85.79 ,$257.38 ,$214.49 ,$228.78 ,$237.36
Hoopeston Regional Hlth Center,8980250,desmopressin 0.2 mg tablet,60687012021,,250,$24.75 ,$24.75 ,$6.93 ,$22.65 ,$17.33 ,$20.72 ,$22.65 ,$22.65 ,$22.65 ,$9.12 ,$14.85 ,$7.43 ,$22.28 ,$18.56 ,$19.80 ,$20.54
Hoopeston Regional Hlth Center,8980250,phenytoin 50 mg chewable tablet,60687015625,,250,$4.01 ,$4.01 ,$1.12 ,$3.67 ,$2.81 ,$3.36 ,$3.67 ,$3.67 ,$3.67 ,$1.48 ,$2.41 ,$1.20 ,$3.61 ,$3.01 ,$3.21 ,$3.33
Hoopeston Regional Hlth Center,8980250,memantine 5 mg tablet,60687017357,,250,$6.06 ,$6.06 ,$1.70 ,$5.54 ,$4.24 ,$5.07 ,$5.54 ,$5.54 ,$5.54 ,$2.23 ,$3.64 ,$1.82 ,$5.45 ,$4.55 ,$4.85 ,$5.03
Hoopeston Regional Hlth Center,8980250,simvastatin 40 mg tablet,60687021001,,250,$25.26 ,$25.26 ,$7.07 ,$23.11 ,$17.68 ,$21.14 ,$23.11 ,$23.11 ,$23.11 ,$9.31 ,$15.16 ,$7.58 ,$22.73 ,$18.95 ,$20.21 ,$20.97
Hoopeston Regional Hlth Center,8980250,rosuvastatin 10 mg tablet,60687024511,,250,$33.15 ,$33.15 ,$9.28 ,$30.33 ,$23.21 ,$27.75 ,$30.33 ,$30.33 ,$30.33 ,$12.22 ,$19.89 ,$9.95 ,$29.84 ,$24.86 ,$26.52 ,$27.51
Hoopeston Regional Hlth Center,8980250,rosuvastatin 20 mg tablet,60687025601,,250,$33.15 ,$33.15 ,$9.28 ,$30.33 ,$23.21 ,$27.75 ,$30.33 ,$30.33 ,$30.33 ,$12.22 ,$19.89 ,$9.95 ,$29.84 ,$24.86 ,$26.52 ,$27.51
Hoopeston Regional Hlth Center,8980250,rosuvastatin 20 mg tablet,60687025611,,250,$33.15 ,$33.15 ,$9.28 ,$30.33 ,$23.21 ,$27.75 ,$30.33 ,$30.33 ,$30.33 ,$12.22 ,$19.89 ,$9.95 ,$29.84 ,$24.86 ,$26.52 ,$27.51
Hoopeston Regional Hlth Center,8980250,traZODone 100 mg tablet,60687045401,,250,$3.36 ,$3.36 ,$0.94 ,$3.07 ,$2.35 ,$2.81 ,$3.07 ,$3.07 ,$3.07 ,$1.24 ,$2.02 ,$1.01 ,$3.02 ,$2.52 ,$2.69 ,$2.79
Hoopeston Regional Hlth Center,8980250,"prednisoLONE acetate 1 % eye drops,suspension",60758011905,,250,$267.02 ,$267.02 ,$74.77 ,$244.32 ,$186.91 ,$223.50 ,$244.32 ,$244.32 ,$244.32 ,$98.40 ,$160.21 ,$80.11 ,$240.32 ,$200.27 ,$213.62 ,$221.63
Hoopeston Regional Hlth Center,8980250,gentamicin 0.3 % eye drops,60758018805,,250,$110.35 ,$110.35 ,$30.90 ,$100.97 ,$77.25 ,$92.36 ,$100.97 ,$100.97 ,$100.97 ,$40.66 ,$66.21 ,$33.11 ,$99.32 ,$82.76 ,$88.28 ,$91.59
Hoopeston Regional Hlth Center,8980250,ketorolac 0.4 % eye drops,60758077305,,250,$332.63 ,$332.63 ,$93.14 ,$304.36 ,$232.84 ,$278.41 ,$304.36 ,$304.36 ,$304.36 ,$122.57 ,$199.58 ,$99.79 ,$299.37 ,$249.47 ,$266.10 ,$276.08
Hoopeston Regional Hlth Center,8980250,"thrombin (bovine) 5,000 unit topical solution",60793021505,,250,$311.11 ,$311.11 ,$87.11 ,$284.67 ,$217.78 ,$260.40 ,$284.67 ,$284.67 ,$284.67 ,$114.64 ,$186.67 ,$93.33 ,$280.00 ,$233.33 ,$248.89 ,$258.22
Hoopeston Regional Hlth Center,8980250,"thrombin (bovine) 20,000 unit topical solution",60793021720,,250,"$1,202.88 ","$1,202.88 ",$336.81 ,"$1,100.64 ",$842.02 ,"$1,006.81 ","$1,100.64 ","$1,100.64 ","$1,100.64 ",$443.26 ,$721.73 ,$360.86 ,"$1,082.59 ",$902.16 ,$962.30 ,$998.39
Hoopeston Regional Hlth Center,8980250,"thrombin (bovine) 20,000 unit topical spray syringe",60793021722,,250,"$1,262.66 ","$1,262.66 ",$353.54 ,"$1,155.33 ",$883.86 ,"$1,056.85 ","$1,155.33 ","$1,155.33 ","$1,155.33 ",$465.29 ,$757.60 ,$378.80 ,"$1,136.39 ",$947.00 ,"$1,010.13 ","$1,048.01 "
Hoopeston Regional Hlth Center,8980250,proparacaine 0.5 % eye drops,61314001601,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,dorzolamide 2 % eye drops,61314001910,,250,$332.03 ,$332.03 ,$92.97 ,$303.81 ,$232.42 ,$277.91 ,$303.81 ,$303.81 ,$303.81 ,$122.35 ,$199.22 ,$99.61 ,$298.83 ,$249.02 ,$265.62 ,$275.58
Hoopeston Regional Hlth Center,8980250,trifluridine 1 % eye drops,61314004475,,250,"$1,059.86 ","$1,059.86 ",$296.76 ,$969.77 ,$741.90 ,$887.10 ,$969.77 ,$969.77 ,$969.77 ,$390.56 ,$635.92 ,$317.96 ,$953.87 ,$794.90 ,$847.89 ,$879.68
Hoopeston Regional Hlth Center,8980250,ketorolac 0.5 % eye drops,61314012605,,250,$512.60 ,$512.60 ,$143.53 ,$469.03 ,$358.82 ,$429.05 ,$469.03 ,$469.03 ,$469.03 ,$188.89 ,$307.56 ,$153.78 ,$461.34 ,$384.45 ,$410.08 ,$425.46
Hoopeston Regional Hlth Center,8980250,pilocarpine 1 % eye drops,61314020315,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,pilocarpine 2 % eye drops,61314020415,,250,$490.77 ,$490.77 ,$137.42 ,$449.05 ,$343.54 ,$410.77 ,$449.05 ,$449.05 ,$449.05 ,$180.85 ,$294.46 ,$147.23 ,$441.69 ,$368.08 ,$392.62 ,$407.34
Hoopeston Regional Hlth Center,8980250,pilocarpine 4 % eye drops,61314020615,,250,$513.49 ,$513.49 ,$143.78 ,$469.84 ,$359.44 ,$429.79 ,$469.84 ,$469.84 ,$469.84 ,$189.22 ,$308.09 ,$154.05 ,$462.14 ,$385.12 ,$410.79 ,$426.20
Hoopeston Regional Hlth Center,8980250,timoloL maleate 0.25 % eye drops,61314022605,,250,$90.80 ,$90.80 ,$25.42 ,$83.08 ,$63.56 ,$76.00 ,$83.08 ,$83.08 ,$83.08 ,$33.46 ,$54.48 ,$27.24 ,$81.72 ,$68.10 ,$72.64 ,$75.36
Hoopeston Regional Hlth Center,8980250,tropicamide 0.5 % eye drops,61314035401,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,tropicamide 1 % eye drops,61314035501,J3490,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,tropicamide 1 % eye drops,61314035502,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,cyclopentolate 1 % eye drops,61314039601,,250,$99.26 ,$99.26 ,$27.79 ,$90.82 ,$69.48 ,$83.08 ,$90.82 ,$90.82 ,$90.82 ,$36.58 ,$59.56 ,$29.78 ,$89.33 ,$74.45 ,$79.41 ,$82.39
Hoopeston Regional Hlth Center,8980250,latanoprost 0.005 % eye drops,61314054701,,250,$463.67 ,$463.67 ,$129.83 ,$424.26 ,$324.57 ,$388.09 ,$424.26 ,$424.26 ,$424.26 ,$170.86 ,$278.20 ,$139.10 ,$417.30 ,$347.75 ,$370.94 ,$384.85
Hoopeston Regional Hlth Center,8980250,"polymyxin B sulfate 10,000 unit-trimethoprim 1 mg/mL eye drops",61314062810,,250,$102.15 ,$102.15 ,$28.60 ,$93.47 ,$71.51 ,$85.50 ,$93.47 ,$93.47 ,$93.47 ,$37.64 ,$61.29 ,$30.65 ,$91.94 ,$76.61 ,$81.72 ,$84.78
Hoopeston Regional Hlth Center,8980250,"neomycin 3.5 mg/g-polymyxin B 10,000 unit/g-dexameth 0.1 % eye oint",61314063136,,250,$200.38 ,$200.38 ,$56.11 ,$183.35 ,$140.27 ,$167.72 ,$183.35 ,$183.35 ,$183.35 ,$73.84 ,$120.23 ,$60.11 ,$180.34 ,$150.29 ,$160.30 ,$166.32
Hoopeston Regional Hlth Center,8980250,"tobramycin 0.3 %-dexamethasone 0.1 % eye drops,suspension",61314064725,,250,$359.10 ,$359.10 ,$100.55 ,$328.58 ,$251.37 ,$300.57 ,$328.58 ,$328.58 ,$328.58 ,$132.33 ,$215.46 ,$107.73 ,$323.19 ,$269.33 ,$287.28 ,$298.05
Hoopeston Regional Hlth Center,8980250,sulfacetamide sodium 10 % eye drops,61314070101,,250,$280.30 ,$280.30 ,$78.48 ,$256.47 ,$196.21 ,$234.61 ,$256.47 ,$256.47 ,$256.47 ,$103.29 ,$168.18 ,$84.09 ,$252.27 ,$210.23 ,$224.24 ,$232.65
Hoopeston Regional Hlth Center,8980250,"mvi, adult no.1 with vit K 3,300 unit-150 mcg/10 mL intravenous soln",61703043482,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,pyrazinamide 500 mg tablet,61748001201,,250,$29.69 ,$29.69 ,$8.31 ,$27.17 ,$20.78 ,$24.85 ,$27.17 ,$27.17 ,$27.17 ,$10.94 ,$17.81 ,$8.91 ,$26.72 ,$22.27 ,$23.75 ,$24.64
Hoopeston Regional Hlth Center,8980250,ethosuximide 250 mg capsule,61748002501,,250,$12.73 ,$12.73 ,$3.56 ,$11.65 ,$8.91 ,$10.66 ,$11.65 ,$11.65 ,$11.65 ,$4.69 ,$7.64 ,$3.82 ,$11.46 ,$9.55 ,$10.18 ,$10.57
Hoopeston Regional Hlth Center,8980250,alirocumab 150 mg/mL subcutaneous pen injector,61755002102,,250,"$1,095.49 ","$1,095.49 ",$306.74 ,"$1,002.37 ",$766.84 ,$916.93 ,"$1,002.37 ","$1,002.37 ","$1,002.37 ",$403.69 ,$657.29 ,$328.65 ,$985.94 ,$821.62 ,$876.39 ,$909.26
Hoopeston Regional Hlth Center,8980250,sodium hyaluronate 16 mg/mL intraocular syringe,61772060081,,250,$760.54 ,$760.54 ,$212.95 ,$695.89 ,$532.38 ,$636.57 ,$695.89 ,$695.89 ,$695.89 ,$280.26 ,$456.32 ,$228.16 ,$684.49 ,$570.41 ,$608.43 ,$631.25
Hoopeston Regional Hlth Center,8980250,emtricitabine 200 mg capsule,61958060101,,250,$83.26 ,$83.26 ,$23.31 ,$76.18 ,$58.28 ,$69.69 ,$76.18 ,$76.18 ,$76.18 ,$30.68 ,$49.96 ,$24.98 ,$74.93 ,$62.45 ,$66.61 ,$69.11
Hoopeston Regional Hlth Center,8980250,remdesivir 100 mg intravenous powder for solution,61958290101,,250,"$2,971.91 ","$2,971.91 ",$832.13 ,"$2,719.30 ","$2,080.34 ","$2,487.49 ","$2,719.30 ","$2,719.30 ","$2,719.30 ","$1,095.15 ","$1,783.15 ",$891.57 ,"$2,674.72 ","$2,228.93 ","$2,377.53 ","$2,466.69 "
Hoopeston Regional Hlth Center,8980250,remdesivir 100 mg/20 mL (5 mg/mL) IV soln (for pts 40 kg or more),61958290201,,250,"$2,971.91 ","$2,971.91 ",$832.13 ,"$2,719.30 ","$2,080.34 ","$2,487.49 ","$2,719.30 ","$2,719.30 ","$2,719.30 ","$1,095.15 ","$1,783.15 ",$891.57 ,"$2,674.72 ","$2,228.93 ","$2,377.53 ","$2,466.69 "
Hoopeston Regional Hlth Center,8980250,"dilTIAZem ER 240 mg capsule,24 hr,extended release",62037069890,,250,$10.61 ,$10.61 ,$2.97 ,$9.71 ,$7.43 ,$8.88 ,$9.71 ,$9.71 ,$9.71 ,$3.91 ,$6.37 ,$3.18 ,$9.55 ,$7.96 ,$8.49 ,$8.81
Hoopeston Regional Hlth Center,8980250,isosorbide mononitrate 20 mg tablet,62175010701,,250,$5.28 ,$5.28 ,$1.48 ,$4.83 ,$3.70 ,$4.42 ,$4.83 ,$4.83 ,$4.83 ,$1.95 ,$3.17 ,$1.58 ,$4.75 ,$3.96 ,$4.22 ,$4.38
Hoopeston Regional Hlth Center,8980250,"isosorbide mononitrate ER 30 mg tablet,extended release 24 hr",62175012837,,250,$4.73 ,$4.73 ,$1.32 ,$4.33 ,$3.31 ,$3.96 ,$4.33 ,$4.33 ,$4.33 ,$1.74 ,$2.84 ,$1.42 ,$4.26 ,$3.55 ,$3.78 ,$3.93
Hoopeston Regional Hlth Center,8980250,lamoTRIgine 25 mg tablet,62332003731,,250,$21.66 ,$21.66 ,$6.06 ,$19.82 ,$15.16 ,$18.13 ,$19.82 ,$19.82 ,$19.82 ,$7.98 ,$13.00 ,$6.50 ,$19.49 ,$16.25 ,$17.33 ,$17.98
Hoopeston Regional Hlth Center,8980250,valsartan 40 mg tablet,62332004490,,250,$20.45 ,$20.45 ,$5.73 ,$18.71 ,$14.32 ,$17.12 ,$18.71 ,$18.71 ,$18.71 ,$7.54 ,$12.27 ,$6.14 ,$18.41 ,$15.34 ,$16.36 ,$16.97
Hoopeston Regional Hlth Center,8980250,valsartan 160 mg tablet,62332004690,,250,$25.62 ,$25.62 ,$7.17 ,$23.44 ,$17.93 ,$21.44 ,$23.44 ,$23.44 ,$23.44 ,$9.44 ,$15.37 ,$7.69 ,$23.06 ,$19.22 ,$20.50 ,$21.26
Hoopeston Regional Hlth Center,8980250,olmesartan 20 mg tablet,62332013230,,250,$30.12 ,$30.12 ,$8.43 ,$27.56 ,$21.08 ,$25.21 ,$27.56 ,$27.56 ,$27.56 ,$11.10 ,$18.07 ,$9.04 ,$27.11 ,$22.59 ,$24.10 ,$25.00
Hoopeston Regional Hlth Center,8980250,diphenoxylate-atropine 2.5 mg-0.025 mg tablet,62559049001,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,metoprolol tartrate 50 mg tablet,62584026601,,250,$2.95 ,$2.95 ,$0.83 ,$2.70 ,$2.07 ,$2.47 ,$2.70 ,$2.70 ,$2.70 ,$1.09 ,$1.77 ,$0.89 ,$2.66 ,$2.21 ,$2.36 ,$2.45
Hoopeston Regional Hlth Center,8980250,hydrALAZINE 50 mg tablet,62584073401,,250,$4.38 ,$4.38 ,$1.23 ,$4.01 ,$3.07 ,$3.67 ,$4.01 ,$4.01 ,$4.01 ,$1.61 ,$2.63 ,$1.31 ,$3.94 ,$3.29 ,$3.50 ,$3.64
Hoopeston Regional Hlth Center,8980250,warfarin 2 mg tablet,62584098401,,250,$5.20 ,$5.20 ,$1.46 ,$4.76 ,$3.64 ,$4.35 ,$4.76 ,$4.76 ,$4.76 ,$1.92 ,$3.12 ,$1.56 ,$4.68 ,$3.90 ,$4.16 ,$4.32
Hoopeston Regional Hlth Center,8980250,warfarin 5 mg tablet,62584099401,,250,$5.33 ,$5.33 ,$1.49 ,$4.88 ,$3.73 ,$4.46 ,$4.88 ,$4.88 ,$4.88 ,$1.96 ,$3.20 ,$1.60 ,$4.80 ,$4.00 ,$4.26 ,$4.42
Hoopeston Regional Hlth Center,8980250,"metFORMIN ER 750 mg tablet,extended release 24 hr",62756014301,,250,$7.91 ,$7.91 ,$2.21 ,$7.24 ,$5.54 ,$6.62 ,$7.24 ,$7.24 ,$7.24 ,$2.91 ,$4.75 ,$2.37 ,$7.12 ,$5.93 ,$6.33 ,$6.57
Hoopeston Regional Hlth Center,8980250,carbidopa 10 mg-levodopa 100 mg tablet,62756051788,,250,$5.63 ,$5.63 ,$1.58 ,$5.15 ,$3.94 ,$4.71 ,$5.15 ,$5.15 ,$5.15 ,$2.07 ,$3.38 ,$1.69 ,$5.07 ,$4.22 ,$4.50 ,$4.67
Hoopeston Regional Hlth Center,8980250,carbidopa 25 mg-levodopa 100 mg tablet,62756051888,,250,$6.06 ,$6.06 ,$1.70 ,$5.54 ,$4.24 ,$5.07 ,$5.54 ,$5.54 ,$5.54 ,$2.23 ,$3.64 ,$1.82 ,$5.45 ,$4.55 ,$4.85 ,$5.03
Hoopeston Regional Hlth Center,8980250,SUMAtriptan 50 mg tablet,62756052169,,250,$96.14 ,$96.14 ,$26.92 ,$87.97 ,$67.30 ,$80.47 ,$87.97 ,$87.97 ,$87.97 ,$35.43 ,$57.68 ,$28.84 ,$86.53 ,$72.11 ,$76.91 ,$79.80
Hoopeston Regional Hlth Center,8980250,perampaneL 2 mg tablet,62856027230,,250,$85.11 ,$85.11 ,$23.83 ,$77.88 ,$59.58 ,$71.24 ,$77.88 ,$77.88 ,$77.88 ,$31.36 ,$51.07 ,$25.53 ,$76.60 ,$63.83 ,$68.09 ,$70.64
Hoopeston Regional Hlth Center,8980250,perampaneL 6 mg tablet,62856027630,,250,$157.91 ,$157.91 ,$44.21 ,$144.49 ,$110.54 ,$132.17 ,$144.49 ,$144.49 ,$144.49 ,$58.19 ,$94.75 ,$47.37 ,$142.12 ,$118.43 ,$126.33 ,$131.07
Hoopeston Regional Hlth Center,8980250,perampaneL 8 mg tablet,62856027830,,250,$157.91 ,$157.91 ,$44.21 ,$144.49 ,$110.54 ,$132.17 ,$144.49 ,$144.49 ,$144.49 ,$58.19 ,$94.75 ,$47.37 ,$142.12 ,$118.43 ,$126.33 ,$131.07
Hoopeston Regional Hlth Center,8980250,perampaneL 12 mg tablet,62856028230,,250,$157.91 ,$157.91 ,$44.21 ,$144.49 ,$110.54 ,$132.17 ,$144.49 ,$144.49 ,$144.49 ,$58.19 ,$94.75 ,$47.37 ,$142.12 ,$118.43 ,$126.33 ,$131.07
Hoopeston Regional Hlth Center,8980250,lidocaine HCl (bulk) 100 % powder,62991109502,,250,$13.98 ,$13.98 ,$3.91 ,$12.79 ,$9.79 ,$11.70 ,$12.79 ,$12.79 ,$12.79 ,$5.15 ,$8.39 ,$4.19 ,$12.58 ,$10.49 ,$11.18 ,$11.60
Hoopeston Regional Hlth Center,8980250,tetracaine HCl (bulk) powder,62991206702,,250,"$5,829.32 ","$5,829.32 ","$1,632.21 ","$5,333.83 ","$4,080.52 ","$4,879.14 ","$5,333.83 ","$5,333.83 ","$5,333.83 ","$2,148.10 ","$3,497.59 ","$1,748.80 ","$5,246.39 ","$4,371.99 ","$4,663.46 ","$4,838.34 "
Hoopeston Regional Hlth Center,8980250,EPINEPHrine bitartrate (bulk) powder,62991286302,,250,$31.34 ,$31.34 ,$8.78 ,$28.68 ,$21.94 ,$26.23 ,$28.68 ,$28.68 ,$28.68 ,$11.55 ,$18.80 ,$9.40 ,$28.21 ,$23.51 ,$25.07 ,$26.01
Hoopeston Regional Hlth Center,8980250,"prenatal vit no.136-ferrous fumarate 27 mg iron-folic acid 1 mg tablet,prenatal vitamin with calcium no.72-iron 27 mg-folic acid 1 mg tablet",63044015001,,250,$2.94 ,$2.94 ,$0.82 ,$2.69 ,$2.06 ,$2.46 ,$2.69 ,$2.69 ,$2.69 ,$1.08 ,$1.76 ,$0.88 ,$2.65 ,$2.21 ,$2.35 ,$2.44
Hoopeston Regional Hlth Center,8980250,hydrOXYchloroQUINE 200 mg tablet,63304029601,,250,$21.38 ,$21.38 ,$5.99 ,$19.56 ,$14.97 ,$17.90 ,$19.56 ,$19.56 ,$19.56 ,$7.88 ,$12.83 ,$6.41 ,$19.24 ,$16.04 ,$17.10 ,$17.75
Hoopeston Regional Hlth Center,8980250,clindamycin HCL 150 mg capsule,63304069201,,250,$13.44 ,$13.44 ,$3.76 ,$12.30 ,$9.41 ,$11.25 ,$12.30 ,$12.30 ,$12.30 ,$4.95 ,$8.06 ,$4.03 ,$12.10 ,$10.08 ,$10.75 ,$11.16
Hoopeston Regional Hlth Center,8980250,pentamidine 300 mg solution for injection,63323011310,,250,$997.32 ,$997.32 ,$279.25 ,$912.55 ,$698.12 ,$834.76 ,$912.55 ,$912.55 ,$912.55 ,$367.51 ,$598.39 ,$299.20 ,$897.59 ,$747.99 ,$797.86 ,$827.78
Hoopeston Regional Hlth Center,8980250,doxycycline hyclate 100 mg intravenous powder for solution,63323013011,,250,$211.31 ,$211.31 ,$59.17 ,$193.35 ,$147.92 ,$176.87 ,$193.35 ,$193.35 ,$193.35 ,$77.87 ,$126.79 ,$63.39 ,$190.18 ,$158.48 ,$169.05 ,$175.39
Hoopeston Regional Hlth Center,8980250,folic acid 5 mg/mL injection solution,63323018410,,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,sodium chloride 4 mEq/mL intravenous solution,63323018730,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,Propofol 10 mg/mL IV,63323026950,,250,$108.16 ,$108.16 ,$30.28 ,$98.97 ,$75.71 ,$90.53 ,$98.97 ,$98.97 ,$98.97 ,$39.86 ,$64.90 ,$32.45 ,$97.34 ,$81.12 ,$86.53 ,$89.77
Hoopeston Regional Hlth Center,8980250,propofol 10 mg/mL IV,63323026965,,250,$212.92 ,$212.92 ,$59.62 ,$194.82 ,$149.04 ,$178.21 ,$194.82 ,$194.82 ,$194.82 ,$78.46 ,$127.75 ,$63.88 ,$191.63 ,$159.69 ,$170.34 ,$176.72
Hoopeston Regional Hlth Center,8980250,propofol 10 mg/mL IV,63323027050,,250,$101.28 ,$101.28 ,$28.36 ,$92.67 ,$70.90 ,$84.77 ,$92.67 ,$92.67 ,$92.67 ,$37.32 ,$60.77 ,$30.38 ,$91.15 ,$75.96 ,$81.02 ,$84.06
Hoopeston Regional Hlth Center,8980250,nafcillin 1 gram solution for injection,63323032710,,250,$138.93 ,$138.93 ,$38.90 ,$127.12 ,$97.25 ,$116.28 ,$127.12 ,$127.12 ,$127.12 ,$51.20 ,$83.36 ,$41.68 ,$125.04 ,$104.20 ,$111.14 ,$115.31
Hoopeston Regional Hlth Center,8980250,nafcillin 2 gram solution for injection,63323032820,,250,$225.62 ,$225.62 ,$63.17 ,$206.44 ,$157.93 ,$188.84 ,$206.44 ,$206.44 ,$206.44 ,$83.14 ,$135.37 ,$67.69 ,$203.06 ,$169.22 ,$180.50 ,$187.26
Hoopeston Regional Hlth Center,8980250,nafcillin 10 gram solution for injection,63323033060,,250,$855.62 ,$855.62 ,$239.57 ,$782.89 ,$598.93 ,$716.15 ,$782.89 ,$782.89 ,$782.89 ,$315.30 ,$513.37 ,$256.69 ,$770.06 ,$641.72 ,$684.50 ,$710.16
Hoopeston Regional Hlth Center,8980250,imipenem-cilastatin 250 mg intravenous solution,63323034925,J0743,250,$130.56 ,$130.56 ,$36.56 ,$119.46 ,$91.39 ,$109.28 ,$119.46 ,$119.46 ,$119.46 ,$48.11 ,$78.34 ,$39.17 ,$117.50 ,$97.92 ,$104.45 ,$108.36
Hoopeston Regional Hlth Center,8980250,"polymyxin B sulfate 500,000 unit solution for injection",63323036711,,250,$111.77 ,$111.77 ,$31.30 ,$102.27 ,$78.24 ,$93.55 ,$102.27 ,$102.27 ,$102.27 ,$41.19 ,$67.06 ,$33.53 ,$100.59 ,$83.83 ,$89.42 ,$92.77
Hoopeston Regional Hlth Center,8980250,flumazeniL 0.1 mg/mL intravenous solution,63323042405,,250,$50.75 ,$50.75 ,$14.21 ,$46.44 ,$35.53 ,$42.48 ,$46.44 ,$46.44 ,$46.44 ,$18.70 ,$30.45 ,$15.23 ,$45.68 ,$38.06 ,$40.60 ,$42.12
Hoopeston Regional Hlth Center,8980250,"lidocaine 1 %-epinephrine 1:100,000 injection solution",63323048257,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,"lidocaine-epinephrine (PF) 1 %-1:200,000 injection solution",63323048717,J3490,250,$54.97 ,$54.97 ,$15.39 ,$50.30 ,$38.48 ,$46.01 ,$50.30 ,$50.30 ,$50.30 ,$20.26 ,$32.98 ,$16.49 ,$49.47 ,$41.23 ,$43.98 ,$45.63
Hoopeston Regional Hlth Center,8980250,"lidocaine-epinephrine (PF) 1.5 %-1:200,000 injection solution",63323048831,,250,$83.54 ,$83.54 ,$23.39 ,$76.44 ,$58.48 ,$69.92 ,$76.44 ,$76.44 ,$76.44 ,$30.78 ,$50.12 ,$25.06 ,$75.19 ,$62.66 ,$66.83 ,$69.34
Hoopeston Regional Hlth Center,8980250,"lidocaine-epinephrine (PF) 2 %-1:200,000 injection solution",63323048917,,250,$65.79 ,$65.79 ,$18.42 ,$60.20 ,$46.05 ,$55.07 ,$60.20 ,$60.20 ,$60.20 ,$24.24 ,$39.47 ,$19.74 ,$59.21 ,$49.34 ,$52.63 ,$54.61
Hoopeston Regional Hlth Center,8980250,"lidocaine-epinephrine (PF) 2 %-1:200,000 injection solution",63323048921,,250,$92.91 ,$92.91 ,$26.01 ,$85.01 ,$65.04 ,$77.77 ,$85.01 ,$85.01 ,$85.01 ,$34.24 ,$55.75 ,$27.87 ,$83.62 ,$69.68 ,$74.33 ,$77.12
Hoopeston Regional Hlth Center,8980250,valproate sodium 500 mg/5 mL (100 mg/mL) intravenous solution,63323049405,J3490,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,levothyroxine 100 mcg intravenous powder for solution,63323064907,,250,$565.59 ,$565.59 ,$158.37 ,$517.51 ,$395.91 ,$473.40 ,$517.51 ,$517.51 ,$517.51 ,$208.42 ,$339.35 ,$169.68 ,$509.03 ,$424.19 ,$452.47 ,$469.44
Hoopeston Regional Hlth Center,8980250,indomethacin 1 mg intravenous solution,63323065903,,250,"$3,021.91 ","$3,021.91 ",$846.13 ,"$2,765.05 ","$2,115.34 ","$2,529.34 ","$2,765.05 ","$2,765.05 ","$2,765.05 ","$1,113.57 ","$1,813.15 ",$906.57 ,"$2,719.72 ","$2,266.43 ","$2,417.53 ","$2,508.19 "
Hoopeston Regional Hlth Center,8980250,acetylcysteine 100 mg/mL (10 %) solution,63323069504,J7608,250,$59.54 ,$59.54 ,$16.67 ,$54.48 ,$41.68 ,$49.83 ,$54.48 ,$54.48 ,$54.48 ,$21.94 ,$35.72 ,$17.86 ,$53.59 ,$44.66 ,$47.63 ,$49.42
Hoopeston Regional Hlth Center,8980250,famotidine (PF) 20 mg/2 mL intravenous solution,63323073912,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,pentamidine 300 mg solution for inhalation,63323087715,J2545,250,$709.10 ,$709.10 ,$198.55 ,$648.83 ,$496.37 ,$593.52 ,$648.83 ,$648.83 ,$648.83 ,$261.30 ,$425.46 ,$212.73 ,$638.19 ,$531.83 ,$567.28 ,$588.55
Hoopeston Regional Hlth Center,8980250,"fentaNYL 100 mcg buccal tablet, effervescent",63459054128,,250,$97.49 ,$97.49 ,$27.30 ,$89.20 ,$68.24 ,$81.60 ,$89.20 ,$89.20 ,$89.20 ,$35.93 ,$58.49 ,$29.25 ,$87.74 ,$73.12 ,$77.99 ,$80.92
Hoopeston Regional Hlth Center,8980250,lidocaine 5 % topical patch,63481068706,,250,$100.33 ,$100.33 ,$28.09 ,$91.80 ,$70.23 ,$83.98 ,$91.80 ,$91.80 ,$91.80 ,$36.97 ,$60.20 ,$30.10 ,$90.30 ,$75.25 ,$80.26 ,$83.27
Hoopeston Regional Hlth Center,8980250,permethrin 1 % topical liquid,63736012002,,250,$61.19 ,$61.19 ,$17.13 ,$55.99 ,$42.83 ,$51.22 ,$55.99 ,$55.99 ,$55.99 ,$22.55 ,$36.71 ,$18.36 ,$55.07 ,$45.89 ,$48.95 ,$50.79
Hoopeston Regional Hlth Center,8980250,hydrALAZINE 25 mg tablet,63739012610,,250,$3.66 ,$3.66 ,$1.02 ,$3.35 ,$2.56 ,$3.06 ,$3.35 ,$3.35 ,$3.35 ,$1.35 ,$2.20 ,$1.10 ,$3.29 ,$2.75 ,$2.93 ,$3.04
Hoopeston Regional Hlth Center,8980250,hydroCHLOROthiazide 25 mg tablet,63739012810,,250,$2.92 ,$2.92 ,$0.82 ,$2.67 ,$2.04 ,$2.44 ,$2.67 ,$2.67 ,$2.67 ,$1.08 ,$1.75 ,$0.88 ,$2.63 ,$2.19 ,$2.34 ,$2.42
Hoopeston Regional Hlth Center,8980250,clonazePAM 0.5 mg tablet,63739026310,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,LORazepam 0.5 mg tablet,63739049910,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,"aspirin 81 mg tablet,delayed release",63739052201,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,QUEtiapine 200 mg tablet,63739067710,,250,$8.04 ,$8.04 ,$2.25 ,$7.36 ,$5.63 ,$6.73 ,$7.36 ,$7.36 ,$7.36 ,$2.96 ,$4.82 ,$2.41 ,$7.24 ,$6.03 ,$6.43 ,$6.67
Hoopeston Regional Hlth Center,8980250,HYDROmorphone 4 mg tablet,63739079110,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,"guaiFENesin ER 600 mg tablet, extended release 12 hr",63824000850,,250,$0.61 ,$0.61 ,$0.17 ,$0.56 ,$0.43 ,$0.51 ,$0.56 ,$0.56 ,$0.56 ,$0.22 ,$0.37 ,$0.18 ,$0.55 ,$0.46 ,$0.49 ,$0.51
Hoopeston Regional Hlth Center,8980250,dextromethorphan polistirex ER 30 mg/5 mL oral susp ext.release 12hr,63824017563,,250,$97.70 ,$97.70 ,$27.36 ,$89.40 ,$68.39 ,$81.77 ,$89.40 ,$89.40 ,$89.40 ,$36.00 ,$58.62 ,$29.31 ,$87.93 ,$73.28 ,$78.16 ,$81.09
Hoopeston Regional Hlth Center,8980250,benzocaine 15 mg-menthoL 2.6 mg lozenges,63824073216,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,oseltamivir 75 mg capsule,64380079901,,250,$62.25 ,$62.25 ,$17.43 ,$56.96 ,$43.58 ,$52.10 ,$56.96 ,$56.96 ,$56.96 ,$22.94 ,$37.35 ,$18.68 ,$56.03 ,$46.69 ,$49.80 ,$51.67
Hoopeston Regional Hlth Center,8980250,ibuprofen 800 mg tablet,64380080706,,250,$6.07 ,$6.07 ,$1.70 ,$5.55 ,$4.25 ,$5.08 ,$5.55 ,$5.55 ,$5.55 ,$2.24 ,$3.64 ,$1.82 ,$5.46 ,$4.55 ,$4.86 ,$5.04
Hoopeston Regional Hlth Center,8980250,vortioxetine 10 mg tablet,64764073030,,250,$67.37 ,$67.37 ,$18.86 ,$61.64 ,$47.16 ,$56.39 ,$61.64 ,$61.64 ,$61.64 ,$24.83 ,$40.42 ,$20.21 ,$60.63 ,$50.53 ,$53.90 ,$55.92
Hoopeston Regional Hlth Center,8980250,miFEPRIStone 200 mg tablet,64875000101,,250,$218.15 ,$218.15 ,$61.08 ,$199.61 ,$152.71 ,$182.59 ,$199.61 ,$199.61 ,$199.61 ,$80.39 ,$130.89 ,$65.45 ,$196.34 ,$163.61 ,$174.52 ,$181.06
Hoopeston Regional Hlth Center,8980250,dipyridamole 25 mg tablet,64980013301,,250,$8.95 ,$8.95 ,$2.51 ,$8.19 ,$6.27 ,$7.49 ,$8.19 ,$8.19 ,$8.19 ,$3.30 ,$5.37 ,$2.69 ,$8.06 ,$6.71 ,$7.16 ,$7.43
Hoopeston Regional Hlth Center,8980250,aMILoride 5 mg tablet,64980015101,,250,$8.29 ,$8.29 ,$2.32 ,$7.59 ,$5.80 ,$6.94 ,$7.59 ,$7.59 ,$7.59 ,$3.05 ,$4.97 ,$2.49 ,$7.46 ,$6.22 ,$6.63 ,$6.88
Hoopeston Regional Hlth Center,8980250,hydrocortisone 2.5 % topical cream with perineal applicator,64980032430,,250,$427.93 ,$427.93 ,$119.82 ,$391.56 ,$299.55 ,$358.18 ,$391.56 ,$391.56 ,$391.56 ,$157.69 ,$256.76 ,$128.38 ,$385.14 ,$320.95 ,$342.34 ,$355.18
Hoopeston Regional Hlth Center,8980250,sertraline 20 mg/mL oral concentrate,64980040906,,250,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,8980250,oxybutynin chloride 5 mg tablet,64980043101,,250,$5.87 ,$5.87 ,$1.64 ,$5.37 ,$4.11 ,$4.91 ,$5.37 ,$5.37 ,$5.37 ,$2.16 ,$3.52 ,$1.76 ,$5.28 ,$4.40 ,$4.70 ,$4.87
Hoopeston Regional Hlth Center,8980250,sevelamer carbonate 800 mg tablet,65162005827,,250,$29.48 ,$29.48 ,$8.25 ,$26.97 ,$20.64 ,$24.67 ,$26.97 ,$26.97 ,$26.97 ,$10.86 ,$17.69 ,$8.84 ,$26.53 ,$22.11 ,$23.58 ,$24.47
Hoopeston Regional Hlth Center,8980250,promethazine 25 mg tablet,65162052110,,250,$4.69 ,$4.69 ,$1.31 ,$4.29 ,$3.28 ,$3.93 ,$4.29 ,$4.29 ,$4.29 ,$1.73 ,$2.81 ,$1.41 ,$4.22 ,$3.52 ,$3.75 ,$3.89
Hoopeston Regional Hlth Center,8980250,"aspirin 25 mg-dipyridamole 200 mg capsule,ext.release 12 hr multiphase",65162059606,,250,$37.39 ,$37.39 ,$10.47 ,$34.21 ,$26.17 ,$31.30 ,$34.21 ,$34.21 ,$34.21 ,$13.78 ,$22.43 ,$11.22 ,$33.65 ,$28.04 ,$29.91 ,$31.03
Hoopeston Regional Hlth Center,8980250,acebutoloL 200 mg capsule,65162066910,,250,$7.81 ,$7.81 ,$2.19 ,$7.15 ,$5.47 ,$6.54 ,$7.15 ,$7.15 ,$7.15 ,$2.88 ,$4.69 ,$2.34 ,$7.03 ,$5.86 ,$6.25 ,$6.48
Hoopeston Regional Hlth Center,8980250,LORazepam 2 mg/mL oral concentrate,65162068784,,250,$16.31 ,$16.31 ,$4.57 ,$14.92 ,$11.42 ,$13.65 ,$14.92 ,$14.92 ,$14.92 ,$6.01 ,$9.79 ,$4.89 ,$14.68 ,$12.23 ,$13.05 ,$13.54
Hoopeston Regional Hlth Center,8980250,escitalopram 5 mg/5 mL oral solution,65162070588,,250,$30.07 ,$30.07 ,$8.42 ,$27.51 ,$21.05 ,$25.17 ,$27.51 ,$27.51 ,$27.51 ,$11.08 ,$18.04 ,$9.02 ,$27.06 ,$22.55 ,$24.06 ,$24.96
Hoopeston Regional Hlth Center,8980250,guanFACINE 1 mg tablet,65162071110,,250,$7.06 ,$7.06 ,$1.98 ,$6.46 ,$4.94 ,$5.91 ,$6.46 ,$6.46 ,$6.46 ,$2.60 ,$4.24 ,$2.12 ,$6.35 ,$5.30 ,$5.65 ,$5.86
Hoopeston Regional Hlth Center,8980250,benazepriL 10 mg tablet,65162075210,,250,$7.23 ,$7.23 ,$2.02 ,$6.62 ,$5.06 ,$6.05 ,$6.62 ,$6.62 ,$6.62 ,$2.66 ,$4.34 ,$2.17 ,$6.51 ,$5.42 ,$5.78 ,$6.00
Hoopeston Regional Hlth Center,8980250,edoxaban 60 mg tablet,65597020305,,250,$62.62 ,$62.62 ,$17.53 ,$57.30 ,$43.83 ,$52.41 ,$57.30 ,$57.30 ,$57.30 ,$23.08 ,$37.57 ,$18.79 ,$56.36 ,$46.97 ,$50.10 ,$51.97
Hoopeston Regional Hlth Center,8980250,rifAXIMin 550 mg tablet,65649030303,,250,$201.18 ,$201.18 ,$56.33 ,$184.08 ,$140.83 ,$168.39 ,$184.08 ,$184.08 ,$184.08 ,$74.13 ,$120.71 ,$60.35 ,$181.06 ,$150.89 ,$160.94 ,$166.98
Hoopeston Regional Hlth Center,8980250,chlorothiazide 250 mg/5 mL oral suspension,65649031112,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,sertraline 50 mg tablet,65862001205,,250,$15.60 ,$15.60 ,$4.37 ,$14.27 ,$10.92 ,$13.06 ,$14.27 ,$14.27 ,$14.27 ,$5.75 ,$9.36 ,$4.68 ,$14.04 ,$11.70 ,$12.48 ,$12.95
Hoopeston Regional Hlth Center,8980250,sertraline 100 mg tablet,65862001305,,250,$15.60 ,$15.60 ,$4.37 ,$14.27 ,$10.92 ,$13.06 ,$14.27 ,$14.27 ,$14.27 ,$5.75 ,$9.36 ,$4.68 ,$14.04 ,$11.70 ,$12.48 ,$12.95
Hoopeston Regional Hlth Center,8980250,zidovudine 10 mg/mL oral syrup,65862004824,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,metoprolol tartrate 25 mg tablet,65862006299,,250,$3.46 ,$3.46 ,$0.97 ,$3.17 ,$2.42 ,$2.90 ,$3.17 ,$3.17 ,$3.17 ,$1.28 ,$2.08 ,$1.04 ,$3.11 ,$2.60 ,$2.77 ,$2.87
Hoopeston Regional Hlth Center,8980250,zidovudine 100 mg capsule,65862010701,,250,$11.74 ,$11.74 ,$3.29 ,$10.74 ,$8.22 ,$9.83 ,$10.74 ,$10.74 ,$10.74 ,$4.33 ,$7.04 ,$3.52 ,$10.57 ,$8.81 ,$9.39 ,$9.74
Hoopeston Regional Hlth Center,8980250,clindamycin HCL 150 mg capsule,65862018501,,250,$13.44 ,$13.44 ,$3.76 ,$12.30 ,$9.41 ,$11.25 ,$12.30 ,$12.30 ,$12.30 ,$4.95 ,$8.06 ,$4.03 ,$12.10 ,$10.08 ,$10.75 ,$11.16
Hoopeston Regional Hlth Center,8980250,losartan 50 mg tablet,65862020299,,250,$12.88 ,$12.88 ,$3.61 ,$11.79 ,$9.02 ,$10.78 ,$11.79 ,$11.79 ,$11.79 ,$4.75 ,$7.73 ,$3.86 ,$11.59 ,$9.66 ,$10.30 ,$10.69
Hoopeston Regional Hlth Center,8980250,"didanosine 400 mg capsule,delayed release",65862031330,,250,$51.17 ,$51.17 ,$14.33 ,$46.82 ,$35.82 ,$42.83 ,$46.82 ,$46.82 ,$46.82 ,$18.86 ,$30.70 ,$15.35 ,$46.05 ,$38.38 ,$40.94 ,$42.47
Hoopeston Regional Hlth Center,8980250,sulfamethoxazole 400 mg-trimethoprim 80 mg tablet,65862041901,,250,$5.43 ,$5.43 ,$1.52 ,$4.97 ,$3.80 ,$4.54 ,$4.97 ,$4.97 ,$4.97 ,$2.00 ,$3.26 ,$1.63 ,$4.89 ,$4.07 ,$4.34 ,$4.51
Hoopeston Regional Hlth Center,8980250,tenofovir disoproxil fumarate 300 mg tablet,65862042130,,250,$142.53 ,$142.53 ,$39.91 ,$130.41 ,$99.77 ,$119.30 ,$130.41 ,$130.41 ,$130.41 ,$52.52 ,$85.52 ,$42.76 ,$128.28 ,$106.90 ,$114.02 ,$118.30
Hoopeston Regional Hlth Center,8980250,galantamine 4 mg tablet,65862045860,,250,$17.16 ,$17.16 ,$4.80 ,$15.70 ,$12.01 ,$14.36 ,$15.70 ,$15.70 ,$15.70 ,$6.32 ,$10.30 ,$5.15 ,$15.44 ,$12.87 ,$13.73 ,$14.24
Hoopeston Regional Hlth Center,8980250,ramipriL 5 mg capsule,65862047601,,250,$11.16 ,$11.16 ,$3.12 ,$10.21 ,$7.81 ,$9.34 ,$10.21 ,$10.21 ,$10.21 ,$4.11 ,$6.70 ,$3.35 ,$10.04 ,$8.37 ,$8.93 ,$9.26
Hoopeston Regional Hlth Center,8980250,naproxen sodium 275 mg tablet,65862051501,,250,$13.00 ,$13.00 ,$3.64 ,$11.90 ,$9.10 ,$10.88 ,$11.90 ,$11.90 ,$11.90 ,$4.79 ,$7.80 ,$3.90 ,$11.70 ,$9.75 ,$10.40 ,$10.79
Hoopeston Regional Hlth Center,8980250,amoxicillin 400 mg-potassium clavulanate 57 mg/5 mL oral suspension,65862053401,,250,$27.04 ,$27.04 ,$7.57 ,$24.74 ,$18.93 ,$22.63 ,$24.74 ,$24.74 ,$24.74 ,$9.96 ,$16.22 ,$8.11 ,$24.34 ,$20.28 ,$21.63 ,$22.44
Hoopeston Regional Hlth Center,8980250,levoFLOXacin 250 mg tablet,65862053650,,250,$66.99 ,$66.99 ,$18.76 ,$61.30 ,$46.89 ,$56.07 ,$61.30 ,$61.30 ,$61.30 ,$24.69 ,$40.19 ,$20.10 ,$60.29 ,$50.24 ,$53.59 ,$55.60
Hoopeston Regional Hlth Center,8980250,levoFLOXacin 500 mg tablet,65862053750,,250,$75.58 ,$75.58 ,$21.16 ,$69.16 ,$52.91 ,$63.26 ,$69.16 ,$69.16 ,$69.16 ,$27.85 ,$45.35 ,$22.67 ,$68.02 ,$56.69 ,$60.46 ,$62.73
Hoopeston Regional Hlth Center,8980250,flecainide 50 mg tablet,65862062101,,250,$11.74 ,$11.74 ,$3.29 ,$10.74 ,$8.22 ,$9.83 ,$10.74 ,$10.74 ,$10.74 ,$4.33 ,$7.04 ,$3.52 ,$10.57 ,$8.81 ,$9.39 ,$9.74
Hoopeston Regional Hlth Center,8980250,rizatriptan 5 mg disintegrating tablet,65862062590,,250,$124.53 ,$124.53 ,$34.87 ,$113.94 ,$87.17 ,$104.23 ,$113.94 ,$113.94 ,$113.94 ,$45.89 ,$74.72 ,$37.36 ,$112.08 ,$93.40 ,$99.62 ,$103.36
Hoopeston Regional Hlth Center,8980250,amiodarone 200 mg tablet,65862073205,,250,$18.09 ,$18.09 ,$5.07 ,$16.55 ,$12.66 ,$15.14 ,$16.55 ,$16.55 ,$16.55 ,$6.67 ,$10.85 ,$5.43 ,$16.28 ,$13.57 ,$14.47 ,$15.01
Hoopeston Regional Hlth Center,8980250,calcium carbonate 200 mg calcium (500 mg) chewable tablet,66553000401,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,sodium bicarbonate 650 mg tablet,66553000801,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,amoxicillin 875 mg-potassium clavulanate 125 mg tablet,66685100101,,250,$25.16 ,$25.16 ,$7.04 ,$23.02 ,$17.61 ,$21.06 ,$23.02 ,$23.02 ,$23.02 ,$9.27 ,$15.10 ,$7.55 ,$22.64 ,$18.87 ,$20.13 ,$20.88
Hoopeston Regional Hlth Center,8980250,amoxicillin 500 mg-potassium clavulanate 125 mg tablet,66685100202,,250,$19.44 ,$19.44 ,$5.44 ,$17.79 ,$13.61 ,$16.27 ,$17.79 ,$17.79 ,$17.79 ,$7.16 ,$11.66 ,$5.83 ,$17.50 ,$14.58 ,$15.55 ,$16.14
Hoopeston Regional Hlth Center,8980250,"nystatin 100,000 unit/mL oral suspension",66689000802,,250,$87.31 ,$87.31 ,$24.45 ,$79.89 ,$61.12 ,$73.08 ,$79.89 ,$79.89 ,$79.89 ,$32.17 ,$52.39 ,$26.19 ,$78.58 ,$65.48 ,$69.85 ,$72.47
Hoopeston Regional Hlth Center,8980250,phenytoin 100 mg/4 mL oral suspension,66689003601,,250,$42.59 ,$42.59 ,$11.93 ,$38.97 ,$29.81 ,$35.65 ,$38.97 ,$38.97 ,$38.97 ,$15.69 ,$25.55 ,$12.78 ,$38.33 ,$31.94 ,$34.07 ,$35.35
Hoopeston Regional Hlth Center,8980250,phenytoin 100 mg/4 mL oral suspension,66689003650,,250,$42.59 ,$42.59 ,$11.93 ,$38.97 ,$29.81 ,$35.65 ,$38.97 ,$38.97 ,$38.97 ,$15.69 ,$25.55 ,$12.78 ,$38.33 ,$31.94 ,$34.07 ,$35.35
Hoopeston Regional Hlth Center,8980250,acetaminophen 650 mg/20.3 mL oral solution,66689005699,,250,$3.98 ,$3.98 ,$1.11 ,$3.64 ,$2.79 ,$3.33 ,$3.64 ,$3.64 ,$3.64 ,$1.47 ,$2.39 ,$1.19 ,$3.58 ,$2.99 ,$3.18 ,$3.30
Hoopeston Regional Hlth Center,8980250,"potassium chloride ER 10 mEq tablet,extended release(part/cryst),potassium chloride ER 10 mEq tablet,extended release",66758017001,,250,$5.11 ,$5.11 ,$1.43 ,$4.68 ,$3.58 ,$4.28 ,$4.68 ,$4.68 ,$4.68 ,$1.88 ,$3.07 ,$1.53 ,$4.60 ,$3.83 ,$4.09 ,$4.24
Hoopeston Regional Hlth Center,8980250,sevoflurane inhalation liquid,66794001525,,250,$714.72 ,$714.72 ,$200.12 ,$653.97 ,$500.30 ,$598.22 ,$653.97 ,$653.97 ,$653.97 ,$263.37 ,$428.83 ,$214.42 ,$643.25 ,$536.04 ,$571.78 ,$593.22
Hoopeston Regional Hlth Center,8980250,isoflurane 99.9 % inhalation liquid,66794001725,,250,$202.71 ,$202.71 ,$56.76 ,$185.48 ,$141.90 ,$169.67 ,$185.48 ,$185.48 ,$185.48 ,$74.70 ,$121.63 ,$60.81 ,$182.44 ,$152.03 ,$162.17 ,$168.25
Hoopeston Regional Hlth Center,8980250,albuterol sulfate HFA 90 mcg/actuation aerosol inhaler,66993001968,,250,$311.95 ,$311.95 ,$87.35 ,$285.43 ,$218.37 ,$261.10 ,$285.43 ,$285.43 ,$285.43 ,$114.95 ,$187.17 ,$93.59 ,$280.76 ,$233.96 ,$249.56 ,$258.92
Hoopeston Regional Hlth Center,8980250,"propafenone ER 225 mg capsule,extended release 12 hr",66993011460,,250,$35.74 ,$35.74 ,$10.01 ,$32.70 ,$25.02 ,$29.91 ,$32.70 ,$32.70 ,$32.70 ,$13.17 ,$21.44 ,$10.72 ,$32.17 ,$26.81 ,$28.59 ,$29.66
Hoopeston Regional Hlth Center,8980250,"carBAMazepine ER 100 mg capsule,extended release mphase12hr",66993040732,,250,$11.48 ,$11.48 ,$3.21 ,$10.50 ,$8.04 ,$9.61 ,$10.50 ,$10.50 ,$10.50 ,$4.23 ,$6.89 ,$3.44 ,$10.33 ,$8.61 ,$9.18 ,$9.53
Hoopeston Regional Hlth Center,8980250,"carBAMazepine ER 200 mg capsule,extended release mphase12hr",66993040832,,250,$11.48 ,$11.48 ,$3.21 ,$10.50 ,$8.04 ,$9.61 ,$10.50 ,$10.50 ,$10.50 ,$4.23 ,$6.89 ,$3.44 ,$10.33 ,$8.61 ,$9.18 ,$9.53
Hoopeston Regional Hlth Center,8980250,fluconazole 100 mg tablet,67405060203,,250,$38.79 ,$38.79 ,$10.86 ,$35.49 ,$27.15 ,$32.47 ,$35.49 ,$35.49 ,$35.49 ,$14.29 ,$23.27 ,$11.64 ,$34.91 ,$29.09 ,$31.03 ,$32.20
Hoopeston Regional Hlth Center,8980250,ketamine 50 mg/mL injection solution,67457000110,,250,$145.61 ,$145.61 ,$40.77 ,$133.23 ,$101.93 ,$121.88 ,$133.23 ,$133.23 ,$133.23 ,$53.66 ,$87.37 ,$43.68 ,$131.05 ,$109.21 ,$116.49 ,$120.86
Hoopeston Regional Hlth Center,8980250,ketamine 10 mg/mL injection solution,67457018120,,250,$146.20 ,$146.20 ,$40.94 ,$133.77 ,$102.34 ,$122.37 ,$133.77 ,$133.77 ,$133.77 ,$53.87 ,$87.72 ,$43.86 ,$131.58 ,$109.65 ,$116.96 ,$121.35
Hoopeston Regional Hlth Center,8980250,remifentaniL 2 mg intravenous solution,67457019805,,250,$636.98 ,$636.98 ,$178.35 ,$582.84 ,$445.89 ,$533.15 ,$582.84 ,$582.84 ,$582.84 ,$234.73 ,$382.19 ,$191.09 ,$573.28 ,$477.74 ,$509.58 ,$528.69
Hoopeston Regional Hlth Center,8980250,methadone 10 mg/mL injection solution,67457021720,J1230,250,$141.65 ,$141.65 ,$39.66 ,$129.61 ,$99.16 ,$118.56 ,$129.61 ,$129.61 ,$129.61 ,$52.20 ,$84.99 ,$42.50 ,$127.49 ,$106.24 ,$113.32 ,$117.57
Hoopeston Regional Hlth Center,8980250,famotidine (PF) 20 mg/2 mL intravenous solution,67457043300,J3490,250,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980250,rifAMPin 600 mg intravenous solution,67457044560,,250,$961.73 ,$961.73 ,$269.28 ,$879.98 ,$673.21 ,$804.97 ,$879.98 ,$879.98 ,$879.98 ,$354.40 ,$577.04 ,$288.52 ,$865.56 ,$721.30 ,$769.38 ,$798.24
Hoopeston Regional Hlth Center,8980250,nitazoxanide 500 mg tablet,67546011112,,250,$573.61 ,$573.61 ,$160.61 ,$524.85 ,$401.53 ,$480.11 ,$524.85 ,$524.85 ,$524.85 ,$211.38 ,$344.17 ,$172.08 ,$516.25 ,$430.21 ,$458.89 ,$476.10
Hoopeston Regional Hlth Center,8980250,docusate sodium 50 mg capsule,67618011128,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,povidone-iodine 10 % topical solution,67618015017,,250,$33.78 ,$33.78 ,$9.46 ,$30.91 ,$23.65 ,$28.27 ,$30.91 ,$30.91 ,$30.91 ,$12.45 ,$20.27 ,$10.13 ,$30.40 ,$25.34 ,$27.02 ,$28.04
Hoopeston Regional Hlth Center,8980250,chlorhexidine gluconate 4 % topical liquid,67618020004,J3490,250,$43.33 ,$43.33 ,$12.13 ,$39.65 ,$30.33 ,$36.27 ,$39.65 ,$39.65 ,$39.65 ,$15.97 ,$26.00 ,$13.00 ,$39.00 ,$32.50 ,$34.66 ,$35.96
Hoopeston Regional Hlth Center,8980250,silver sulfADIAZINE 1 % topical cream,67877012440,,250,$322.94 ,$322.94 ,$90.42 ,$295.49 ,$226.06 ,$270.30 ,$295.49 ,$295.49 ,$295.49 ,$119.00 ,$193.76 ,$96.88 ,$290.65 ,$242.21 ,$258.35 ,$268.04
Hoopeston Regional Hlth Center,8980250,silver sulfADIAZINE 1 % topical cream,67877012450,,250,$91.34 ,$91.34 ,$25.58 ,$83.58 ,$63.94 ,$76.45 ,$83.58 ,$83.58 ,$83.58 ,$33.66 ,$54.80 ,$27.40 ,$82.21 ,$68.51 ,$73.07 ,$75.81
Hoopeston Regional Hlth Center,8980250,amLODIPine 5 mg tablet,67877019810,,250,$10.67 ,$10.67 ,$2.99 ,$9.76 ,$7.47 ,$8.93 ,$9.76 ,$9.76 ,$9.76 ,$3.93 ,$6.40 ,$3.20 ,$9.60 ,$8.00 ,$8.54 ,$8.86
Hoopeston Regional Hlth Center,8980250,ibuprofen 400 mg tablet,67877031901,,250,$4.04 ,$4.04 ,$1.13 ,$3.70 ,$2.83 ,$3.38 ,$3.70 ,$3.70 ,$3.70 ,$1.49 ,$2.42 ,$1.21 ,$3.64 ,$3.03 ,$3.23 ,$3.35
Hoopeston Regional Hlth Center,8980250,itraconazole 100 mg capsule,67877045430,,250,$92.66 ,$92.66 ,$25.94 ,$84.78 ,$64.86 ,$77.56 ,$84.78 ,$84.78 ,$84.78 ,$34.15 ,$55.60 ,$27.80 ,$83.39 ,$69.50 ,$74.13 ,$76.91
Hoopeston Regional Hlth Center,8980250,levETIRAcetam 500 mg tablet,68001011703,,250,$18.71 ,$18.71 ,$5.24 ,$17.12 ,$13.10 ,$15.66 ,$17.12 ,$17.12 ,$17.12 ,$6.89 ,$11.23 ,$5.61 ,$16.84 ,$14.03 ,$14.97 ,$15.53
Hoopeston Regional Hlth Center,8980250,ziprasidone 80 mg capsule,68001013906,,250,$46.22 ,$46.22 ,$12.94 ,$42.29 ,$32.35 ,$38.69 ,$42.29 ,$42.29 ,$42.29 ,$17.03 ,$27.73 ,$13.87 ,$41.60 ,$34.67 ,$36.98 ,$38.36
Hoopeston Regional Hlth Center,8980250,ramipriL 2.5 mg capsule,68001014200,,250,$10.32 ,$10.32 ,$2.89 ,$9.44 ,$7.22 ,$8.64 ,$9.44 ,$9.44 ,$9.44 ,$3.80 ,$6.19 ,$3.10 ,$9.29 ,$7.74 ,$8.26 ,$8.57
Hoopeston Regional Hlth Center,8980250,ramipriL 5 mg capsule,68001014300,,250,$10.71 ,$10.71 ,$3.00 ,$9.80 ,$7.50 ,$8.96 ,$9.80 ,$9.80 ,$9.80 ,$3.95 ,$6.43 ,$3.21 ,$9.64 ,$8.03 ,$8.57 ,$8.89
Hoopeston Regional Hlth Center,8980250,carvediloL 12.5 mg tablet,68001015100,,250,$12.29 ,$12.29 ,$3.44 ,$11.25 ,$8.60 ,$10.29 ,$11.25 ,$11.25 ,$11.25 ,$4.53 ,$7.37 ,$3.69 ,$11.06 ,$9.22 ,$9.83 ,$10.20
Hoopeston Regional Hlth Center,8980250,carvediloL 3.125 mg tablet,68001015300,,250,$12.29 ,$12.29 ,$3.44 ,$11.25 ,$8.60 ,$10.29 ,$11.25 ,$11.25 ,$11.25 ,$4.53 ,$7.37 ,$3.69 ,$11.06 ,$9.22 ,$9.83 ,$10.20
Hoopeston Regional Hlth Center,8980250,carvediloL 6.25 mg tablet,68001015403,,250,$12.29 ,$12.29 ,$3.44 ,$11.25 ,$8.60 ,$10.29 ,$11.25 ,$11.25 ,$11.25 ,$4.53 ,$7.37 ,$3.69 ,$11.06 ,$9.22 ,$9.83 ,$10.20
Hoopeston Regional Hlth Center,8980250,venlafaxine 75 mg tablet,68001016000,,250,$12.51 ,$12.51 ,$3.50 ,$11.45 ,$8.76 ,$10.47 ,$11.45 ,$11.45 ,$11.45 ,$4.61 ,$7.51 ,$3.75 ,$11.26 ,$9.38 ,$10.01 ,$10.38
Hoopeston Regional Hlth Center,8980250,cloNIDine HCL 0.1 mg tablet,68001023703,,250,$3.51 ,$3.51 ,$0.98 ,$3.21 ,$2.46 ,$2.94 ,$3.21 ,$3.21 ,$3.21 ,$1.29 ,$2.11 ,$1.05 ,$3.16 ,$2.63 ,$2.81 ,$2.91
Hoopeston Regional Hlth Center,8980250,famotidine 20 mg tablet,68001024008,,250,$13.62 ,$13.62 ,$3.81 ,$12.46 ,$9.53 ,$11.40 ,$12.46 ,$12.46 ,$12.46 ,$5.02 ,$8.17 ,$4.09 ,$12.26 ,$10.22 ,$10.90 ,$11.30
Hoopeston Regional Hlth Center,8980250,zonisamide 50 mg capsule,68001024300,,250,$7.44 ,$7.44 ,$2.08 ,$6.81 ,$5.21 ,$6.23 ,$6.81 ,$6.81 ,$6.81 ,$2.74 ,$4.46 ,$2.23 ,$6.70 ,$5.58 ,$5.95 ,$6.18
Hoopeston Regional Hlth Center,8980250,lovastatin 20 mg tablet,68001031500,,250,$13.39 ,$13.39 ,$3.75 ,$12.25 ,$9.37 ,$11.21 ,$12.25 ,$12.25 ,$12.25 ,$4.93 ,$8.03 ,$4.02 ,$12.05 ,$10.04 ,$10.71 ,$11.11
Hoopeston Regional Hlth Center,8980250,lovastatin 40 mg tablet,68001031600,,250,$22.23 ,$22.23 ,$6.22 ,$20.34 ,$15.56 ,$18.61 ,$20.34 ,$20.34 ,$20.34 ,$8.19 ,$13.34 ,$6.67 ,$20.01 ,$16.67 ,$17.78 ,$18.45
Hoopeston Regional Hlth Center,8980250,lisinopriL 5 mg tablet,68001033300,,250,$6.86 ,$6.86 ,$1.92 ,$6.28 ,$4.80 ,$5.74 ,$6.28 ,$6.28 ,$6.28 ,$2.53 ,$4.12 ,$2.06 ,$6.17 ,$5.15 ,$5.49 ,$5.69
Hoopeston Regional Hlth Center,8980250,lisinopriL 20 mg tablet,68001033508,,250,$7.34 ,$7.34 ,$2.06 ,$6.72 ,$5.14 ,$6.14 ,$6.72 ,$6.72 ,$6.72 ,$2.70 ,$4.40 ,$2.20 ,$6.61 ,$5.51 ,$5.87 ,$6.09
Hoopeston Regional Hlth Center,8980250,ursodioL 250 mg tablet,68001034300,,250,$14.83 ,$14.83 ,$4.15 ,$13.57 ,$10.38 ,$12.41 ,$13.57 ,$13.57 ,$13.57 ,$5.46 ,$8.90 ,$4.45 ,$13.35 ,$11.12 ,$11.86 ,$12.31
Hoopeston Regional Hlth Center,8980250,"metoprolol succinate ER 25 mg tablet,extended release 24 hr",68001035600,,250,$7.24 ,$7.24 ,$2.03 ,$6.62 ,$5.07 ,$6.06 ,$6.62 ,$6.62 ,$6.62 ,$2.67 ,$4.34 ,$2.17 ,$6.52 ,$5.43 ,$5.79 ,$6.01
Hoopeston Regional Hlth Center,8980250,"metoprolol succinate ER 50 mg tablet,extended release 24 hr",68001035700,,250,$7.24 ,$7.24 ,$2.03 ,$6.62 ,$5.07 ,$6.06 ,$6.62 ,$6.62 ,$6.62 ,$2.67 ,$4.34 ,$2.17 ,$6.52 ,$5.43 ,$5.79 ,$6.01
Hoopeston Regional Hlth Center,8980250,isosorbide dinitrate 20 mg tablet,68001037500,,250,$7.88 ,$7.88 ,$2.21 ,$7.21 ,$5.52 ,$6.60 ,$7.21 ,$7.21 ,$7.21 ,$2.90 ,$4.73 ,$2.36 ,$7.09 ,$5.91 ,$6.30 ,$6.54
Hoopeston Regional Hlth Center,8980250,labetaloL 100 mg tablet,68001038103,,250,$4.60 ,$4.60 ,$1.29 ,$4.21 ,$3.22 ,$3.85 ,$4.21 ,$4.21 ,$4.21 ,$1.70 ,$2.76 ,$1.38 ,$4.14 ,$3.45 ,$3.68 ,$3.82
Hoopeston Regional Hlth Center,8980250,warfarin 2.5 mg tablet,68084002701,,250,$5.29 ,$5.29 ,$1.48 ,$4.84 ,$3.70 ,$4.43 ,$4.84 ,$4.84 ,$4.84 ,$1.95 ,$3.17 ,$1.59 ,$4.76 ,$3.97 ,$4.23 ,$4.39
Hoopeston Regional Hlth Center,8980250,ciprofloxacin 250 mg tablet,68084006901,,250,$27.26 ,$27.26 ,$7.63 ,$24.94 ,$19.08 ,$22.82 ,$24.94 ,$24.94 ,$24.94 ,$10.05 ,$16.36 ,$8.18 ,$24.53 ,$20.45 ,$21.81 ,$22.63
Hoopeston Regional Hlth Center,8980250,ciprofloxacin 250 mg tablet,68084006911,,250,$27.26 ,$27.26 ,$7.63 ,$24.94 ,$19.08 ,$22.82 ,$24.94 ,$24.94 ,$24.94 ,$10.05 ,$16.36 ,$8.18 ,$24.53 ,$20.45 ,$21.81 ,$22.63
Hoopeston Regional Hlth Center,8980250,carbidopa 25 mg-levodopa 250 mg tablet,68084009401,,250,$6.74 ,$6.74 ,$1.89 ,$6.17 ,$4.72 ,$5.64 ,$6.17 ,$6.17 ,$6.17 ,$2.48 ,$4.04 ,$2.02 ,$6.07 ,$5.06 ,$5.39 ,$5.59
Hoopeston Regional Hlth Center,8980250,sertraline 25 mg tablet,68084018001,,250,$4.20 ,$4.20 ,$1.18 ,$3.84 ,$2.94 ,$3.52 ,$3.84 ,$3.84 ,$3.84 ,$1.55 ,$2.52 ,$1.26 ,$3.78 ,$3.15 ,$3.36 ,$3.49
Hoopeston Regional Hlth Center,8980250,zolpidem 5 mg tablet,68084018901,,250,$12.84 ,$12.84 ,$3.60 ,$11.75 ,$8.99 ,$10.75 ,$11.75 ,$11.75 ,$11.75 ,$4.73 ,$7.70 ,$3.85 ,$11.56 ,$9.63 ,$10.27 ,$10.66
Hoopeston Regional Hlth Center,8980250,sulfamethoxazole 800 mg-trimethoprim 160 mg tablet,68084023001,,250,$3.70 ,$3.70 ,$1.04 ,$3.39 ,$2.59 ,$3.10 ,$3.39 ,$3.39 ,$3.39 ,$1.36 ,$2.22 ,$1.11 ,$3.33 ,$2.78 ,$2.96 ,$3.07
Hoopeston Regional Hlth Center,8980250,ethambutoL 400 mg tablet,68084028001,,250,$9.90 ,$9.90 ,$2.77 ,$9.06 ,$6.93 ,$8.29 ,$9.06 ,$9.06 ,$9.06 ,$3.65 ,$5.94 ,$2.97 ,$8.91 ,$7.43 ,$7.92 ,$8.22
Hoopeston Regional Hlth Center,8980250,ethambutoL 400 mg tablet,68084028011,,250,$9.90 ,$9.90 ,$2.77 ,$9.06 ,$6.93 ,$8.29 ,$9.06 ,$9.06 ,$9.06 ,$3.65 ,$5.94 ,$2.97 ,$8.91 ,$7.43 ,$7.92 ,$8.22
Hoopeston Regional Hlth Center,8980250,"carbidopa ER 25 mg-levodopa 100 mg tablet,extended release",68084028101,,250,$6.22 ,$6.22 ,$1.74 ,$5.69 ,$4.35 ,$5.21 ,$5.69 ,$5.69 ,$5.69 ,$2.29 ,$3.73 ,$1.87 ,$5.60 ,$4.67 ,$4.98 ,$5.16
Hoopeston Regional Hlth Center,8980250,"carbidopa ER 50 mg-levodopa 200 mg tablet,extended release",68084028201,,250,$9.70 ,$9.70 ,$2.72 ,$8.88 ,$6.79 ,$8.12 ,$8.88 ,$8.88 ,$8.88 ,$3.57 ,$5.82 ,$2.91 ,$8.73 ,$7.28 ,$7.76 ,$8.05
Hoopeston Regional Hlth Center,8980250,fludrocortisone 0.1 mg tablet,68084028801,,250,$7.25 ,$7.25 ,$2.03 ,$6.63 ,$5.08 ,$6.07 ,$6.63 ,$6.63 ,$6.63 ,$2.67 ,$4.35 ,$2.18 ,$6.53 ,$5.44 ,$5.80 ,$6.02
Hoopeston Regional Hlth Center,8980250,"potassium chloride ER 20 mEq tablet,extended release(part/cryst)",68084036009,,250,$6.05 ,$6.05 ,$1.69 ,$5.54 ,$4.24 ,$5.06 ,$5.54 ,$5.54 ,$5.54 ,$2.23 ,$3.63 ,$1.82 ,$5.45 ,$4.54 ,$4.84 ,$5.02
Hoopeston Regional Hlth Center,8980250,"divalproex ER 500 mg tablet,extended release 24 hr",68084041501,,250,$20.19 ,$20.19 ,$5.65 ,$18.47 ,$14.13 ,$16.90 ,$18.47 ,$18.47 ,$18.47 ,$7.44 ,$12.11 ,$6.06 ,$18.17 ,$15.14 ,$16.15 ,$16.76
Hoopeston Regional Hlth Center,8980250,HYDROmorphone 2 mg tablet,68084042301,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,simvastatin 10 mg tablet,68084051101,,250,$15.33 ,$15.33 ,$4.29 ,$14.03 ,$10.73 ,$12.83 ,$14.03 ,$14.03 ,$14.03 ,$5.65 ,$9.20 ,$4.60 ,$13.80 ,$11.50 ,$12.26 ,$12.72
Hoopeston Regional Hlth Center,8980250,simvastatin 20 mg tablet,68084051201,,250,$25.26 ,$25.26 ,$7.07 ,$23.11 ,$17.68 ,$21.14 ,$23.11 ,$23.11 ,$23.11 ,$9.31 ,$15.16 ,$7.58 ,$22.73 ,$18.95 ,$20.21 ,$20.97
Hoopeston Regional Hlth Center,8980250,"venlafaxine ER 75 mg capsule,extended release 24 hr",68084070901,,250,$21.89 ,$21.89 ,$6.13 ,$20.03 ,$15.32 ,$18.32 ,$20.03 ,$20.03 ,$20.03 ,$8.07 ,$13.13 ,$6.57 ,$19.70 ,$16.42 ,$17.51 ,$18.17
Hoopeston Regional Hlth Center,8980250,"venlafaxine ER 150 mg capsule,extended release 24 hr",68084071301,,250,$23.64 ,$23.64 ,$6.62 ,$21.63 ,$16.55 ,$19.79 ,$21.63 ,$21.63 ,$21.63 ,$8.71 ,$14.18 ,$7.09 ,$21.28 ,$17.73 ,$18.91 ,$19.62
Hoopeston Regional Hlth Center,8980250,OLANZapine 5 mg tablet,68084072301,,250,$46.27 ,$46.27 ,$12.96 ,$42.34 ,$32.39 ,$38.73 ,$42.34 ,$42.34 ,$42.34 ,$17.05 ,$27.76 ,$13.88 ,$41.64 ,$34.70 ,$37.02 ,$38.40
Hoopeston Regional Hlth Center,8980250,methadone 10 mg tablet,68084073801,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,gabapentin 300 mg capsule,68084076201,,250,$8.75 ,$8.75 ,$2.45 ,$8.01 ,$6.13 ,$7.32 ,$8.01 ,$8.01 ,$8.01 ,$3.22 ,$5.25 ,$2.63 ,$7.88 ,$6.56 ,$7.00 ,$7.26
Hoopeston Regional Hlth Center,8980250,gabapentin 400 mg capsule,68084077401,,250,$8.02 ,$8.02 ,$2.25 ,$7.34 ,$5.61 ,$6.71 ,$7.34 ,$7.34 ,$7.34 ,$2.96 ,$4.81 ,$2.41 ,$7.22 ,$6.02 ,$6.42 ,$6.66
Hoopeston Regional Hlth Center,8980250,traMADoL 50 mg tablet,68084080801,,250,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980250,montelukast 10 mg tablet,68084087501,,250,$27.42 ,$27.42 ,$7.68 ,$25.09 ,$19.19 ,$22.95 ,$25.09 ,$25.09 ,$25.09 ,$10.10 ,$16.45 ,$8.23 ,$24.68 ,$20.57 ,$21.94 ,$22.76
Hoopeston Regional Hlth Center,8980250,morphine 10 mg/5 mL oral solution,68094000162,,250,$16.48 ,$16.48 ,$4.61 ,$15.08 ,$11.54 ,$13.79 ,$15.08 ,$15.08 ,$15.08 ,$6.07 ,$9.89 ,$4.94 ,$14.83 ,$12.36 ,$13.18 ,$13.68
Hoopeston Regional Hlth Center,8980250,melatonin 3 mg tablet,68094011061,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,ibuprofen 100 mg/5 mL oral suspension,68094049459,,250,$1.71 ,$1.71 ,$0.48 ,$1.56 ,$1.20 ,$1.43 ,$1.56 ,$1.56 ,$1.56 ,$0.63 ,$1.03 ,$0.51 ,$1.54 ,$1.28 ,$1.37 ,$1.42
Hoopeston Regional Hlth Center,8980250,ibuprofen 100 mg/5 mL oral suspension,68094049462,,250,$1.22 ,$1.22 ,$0.34 ,$1.12 ,$0.85 ,$1.02 ,$1.12 ,$1.12 ,$1.12 ,$0.45 ,$0.73 ,$0.37 ,$1.10 ,$0.92 ,$0.98 ,$1.01
Hoopeston Regional Hlth Center,8980250,acetaminophen 160 mg/5 mL (5 mL) oral suspension,68094058761,,250,$1.40 ,$1.40 ,$0.39 ,$1.28 ,$0.98 ,$1.17 ,$1.28 ,$1.28 ,$1.28 ,$0.52 ,$0.84 ,$0.42 ,$1.26 ,$1.05 ,$1.12 ,$1.16
Hoopeston Regional Hlth Center,8980250,naproxen 125 mg/5 mL oral suspension,68134020116,,250,$47.96 ,$47.96 ,$13.43 ,$43.88 ,$33.57 ,$40.14 ,$43.88 ,$43.88 ,$43.88 ,$17.67 ,$28.78 ,$14.39 ,$43.16 ,$35.97 ,$38.37 ,$39.81
Hoopeston Regional Hlth Center,8980250,cephalexin 250 mg capsule,68180012101,,250,$5.56 ,$5.56 ,$1.56 ,$5.09 ,$3.89 ,$4.65 ,$5.09 ,$5.09 ,$5.09 ,$2.05 ,$3.34 ,$1.67 ,$5.00 ,$4.17 ,$4.45 ,$4.61
Hoopeston Regional Hlth Center,8980250,cefuroxime axetil 250 mg tablet,68180030220,,250,$22.83 ,$22.83 ,$6.39 ,$20.89 ,$15.98 ,$19.11 ,$20.89 ,$20.89 ,$20.89 ,$8.41 ,$13.70 ,$6.85 ,$20.55 ,$17.12 ,$18.26 ,$18.95
Hoopeston Regional Hlth Center,8980250,ziprasidone 20 mg capsule,68180033107,,250,$39.52 ,$39.52 ,$11.07 ,$36.16 ,$27.66 ,$33.08 ,$36.16 ,$36.16 ,$36.16 ,$14.56 ,$23.71 ,$11.86 ,$35.57 ,$29.64 ,$31.62 ,$32.80
Hoopeston Regional Hlth Center,8980250,irbesartan 150 mg tablet,68180041106,,250,$16.64 ,$16.64 ,$4.66 ,$15.23 ,$11.65 ,$13.93 ,$15.23 ,$15.23 ,$15.23 ,$6.13 ,$9.98 ,$4.99 ,$14.98 ,$12.48 ,$13.31 ,$13.81
Hoopeston Regional Hlth Center,8980250,quinapriL 5 mg tablet,68180055609,,250,$8.03 ,$8.03 ,$2.25 ,$7.35 ,$5.62 ,$6.72 ,$7.35 ,$7.35 ,$7.35 ,$2.96 ,$4.82 ,$2.41 ,$7.23 ,$6.02 ,$6.42 ,$6.66
Hoopeston Regional Hlth Center,8980250,"traMADoL ER 300 mg tablet,extended release 24 hr",68180069906,,250,$45.98 ,$45.98 ,$12.87 ,$42.07 ,$32.19 ,$38.49 ,$42.07 ,$42.07 ,$42.07 ,$16.94 ,$27.59 ,$13.79 ,$41.38 ,$34.49 ,$36.78 ,$38.16
Hoopeston Regional Hlth Center,8980250,lisinopriL 10 mg tablet,68180098003,,250,$6.92 ,$6.92 ,$1.94 ,$6.33 ,$4.84 ,$5.79 ,$6.33 ,$6.33 ,$6.33 ,$2.55 ,$4.15 ,$2.08 ,$6.23 ,$5.19 ,$5.54 ,$5.74
Hoopeston Regional Hlth Center,8980250,oxyCODONE 20 mg/mL oral concentrate,68308002003,,250,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,8980250,topiramate 15 mg sprinkle capsule,68382000414,,250,$13.59 ,$13.59 ,$3.81 ,$12.43 ,$9.51 ,$11.37 ,$12.43 ,$12.43 ,$12.43 ,$5.01 ,$8.15 ,$4.08 ,$12.23 ,$10.19 ,$10.87 ,$11.28
Hoopeston Regional Hlth Center,8980250,topiramate 25 mg sprinkle capsule,68382000514,,250,$15.94 ,$15.94 ,$4.46 ,$14.59 ,$11.16 ,$13.34 ,$14.59 ,$14.59 ,$14.59 ,$5.87 ,$9.56 ,$4.78 ,$14.35 ,$11.96 ,$12.75 ,$13.23
Hoopeston Regional Hlth Center,8980250,meloxicam 15 mg tablet,68382005101,,250,$24.91 ,$24.91 ,$6.97 ,$22.79 ,$17.44 ,$20.85 ,$22.79 ,$22.79 ,$22.79 ,$9.18 ,$14.95 ,$7.47 ,$22.42 ,$18.68 ,$19.93 ,$20.68
Hoopeston Regional Hlth Center,8980250,carvediloL 12.5 mg tablet,68382009405,,250,$12.29 ,$12.29 ,$3.44 ,$11.25 ,$8.60 ,$10.29 ,$11.25 ,$11.25 ,$11.25 ,$4.53 ,$7.37 ,$3.69 ,$11.06 ,$9.22 ,$9.83 ,$10.20
Hoopeston Regional Hlth Center,8980250,PARoxetine 20 mg tablet,68382009801,,250,$15.07 ,$15.07 ,$4.22 ,$13.79 ,$10.55 ,$12.61 ,$13.79 ,$13.79 ,$13.79 ,$5.55 ,$9.04 ,$4.52 ,$13.56 ,$11.30 ,$12.06 ,$12.51
Hoopeston Regional Hlth Center,8980250,"divalproex 125 mg capsule,delayed release sprinkle",68382010601,,250,$7.54 ,$7.54 ,$2.11 ,$6.90 ,$5.28 ,$6.31 ,$6.90 ,$6.90 ,$6.90 ,$2.78 ,$4.52 ,$2.26 ,$6.79 ,$5.66 ,$6.03 ,$6.26
Hoopeston Regional Hlth Center,8980250,risperiDONE 0.5 mg tablet,68382011314,,250,$22.28 ,$22.28 ,$6.24 ,$20.39 ,$15.60 ,$18.65 ,$20.39 ,$20.39 ,$20.39 ,$8.21 ,$13.37 ,$6.68 ,$20.05 ,$16.71 ,$17.82 ,$18.49
Hoopeston Regional Hlth Center,8980250,tamsulosin 0.4 mg capsule,68382013201,,250,$21.97 ,$21.97 ,$6.15 ,$20.10 ,$15.38 ,$18.39 ,$20.10 ,$20.10 ,$20.10 ,$8.10 ,$13.18 ,$6.59 ,$19.77 ,$16.48 ,$17.58 ,$18.24
Hoopeston Regional Hlth Center,8980250,nitroglycerin 0.4 mg/hr transdermal 24 hour patch,68382031030,,250,$12.46 ,$12.46 ,$3.49 ,$11.40 ,$8.72 ,$10.43 ,$11.40 ,$11.40 ,$11.40 ,$4.59 ,$7.48 ,$3.74 ,$11.21 ,$9.35 ,$9.97 ,$10.34
Hoopeston Regional Hlth Center,8980250,amantadine HCL 100 mg capsule,68382051201,,250,$11.74 ,$11.74 ,$3.29 ,$10.74 ,$8.22 ,$9.83 ,$10.74 ,$10.74 ,$10.74 ,$4.33 ,$7.04 ,$3.52 ,$10.57 ,$8.81 ,$9.39 ,$9.74
Hoopeston Regional Hlth Center,8980250,"mesalamine 1.2 gram tablet,delayed release",68382071119,,250,$78.91 ,$78.91 ,$22.09 ,$72.20 ,$55.24 ,$66.05 ,$72.20 ,$72.20 ,$72.20 ,$29.08 ,$47.35 ,$23.67 ,$71.02 ,$59.18 ,$63.13 ,$65.50
Hoopeston Regional Hlth Center,8980250,traZODone 50 mg tablet,68382080505,,250,$6.24 ,$6.24 ,$1.75 ,$5.71 ,$4.37 ,$5.22 ,$5.71 ,$5.71 ,$5.71 ,$2.30 ,$3.74 ,$1.87 ,$5.62 ,$4.68 ,$4.99 ,$5.18
Hoopeston Regional Hlth Center,8980250,traZODone 150 mg tablet,68382080701,,250,$15.34 ,$15.34 ,$4.30 ,$14.04 ,$10.74 ,$12.84 ,$14.04 ,$14.04 ,$14.04 ,$5.65 ,$9.20 ,$4.60 ,$13.81 ,$11.51 ,$12.27 ,$12.73
Hoopeston Regional Hlth Center,8980250,stiripentoL 250 mg capsule,68418793906,,250,$113.15 ,$113.15 ,$31.68 ,$103.53 ,$79.21 ,$94.71 ,$103.53 ,$103.53 ,$103.53 ,$41.70 ,$67.89 ,$33.95 ,$101.84 ,$84.86 ,$90.52 ,$93.91
Hoopeston Regional Hlth Center,8980250,stiripentoL 500 mg capsule,68418794006,,250,$218.15 ,$218.15 ,$61.08 ,$199.61 ,$152.71 ,$182.59 ,$199.61 ,$199.61 ,$199.61 ,$80.39 ,$130.89 ,$65.45 ,$196.34 ,$163.61 ,$174.52 ,$181.06
Hoopeston Regional Hlth Center,8980250,fluconazole 150 mg tablet,68462010340,,250,$57.19 ,$57.19 ,$16.01 ,$52.33 ,$40.03 ,$47.87 ,$52.33 ,$52.33 ,$52.33 ,$21.07 ,$34.31 ,$17.16 ,$51.47 ,$42.89 ,$45.75 ,$47.47
Hoopeston Regional Hlth Center,8980250,topiramate 25 mg tablet,68462010860,,250,$12.66 ,$12.66 ,$3.54 ,$11.58 ,$8.86 ,$10.60 ,$11.58 ,$11.58 ,$11.58 ,$4.67 ,$7.60 ,$3.80 ,$11.39 ,$9.50 ,$10.13 ,$10.51
Hoopeston Regional Hlth Center,8980250,zonisamide 100 mg capsule,68462013001,,250,$12.56 ,$12.56 ,$3.52 ,$11.49 ,$8.79 ,$10.51 ,$11.49 ,$11.49 ,$11.49 ,$4.63 ,$7.54 ,$3.77 ,$11.30 ,$9.42 ,$10.05 ,$10.42
Hoopeston Regional Hlth Center,8980250,mupirocin 2 % topical ointment,68462018022,,250,$220.17 ,$220.17 ,$61.65 ,$201.46 ,$154.12 ,$184.28 ,$201.46 ,$201.46 ,$201.46 ,$81.13 ,$132.10 ,$66.05 ,$198.15 ,$165.13 ,$176.14 ,$182.74
Hoopeston Regional Hlth Center,8980250,indomethacin 25 mg capsule,68462040601,,250,$4.20 ,$4.20 ,$1.18 ,$3.84 ,$2.94 ,$3.52 ,$3.84 ,$3.84 ,$3.84 ,$1.55 ,$2.52 ,$1.26 ,$3.78 ,$3.15 ,$3.36 ,$3.49
Hoopeston Regional Hlth Center,8980250,"acamprosate 333 mg tablet,delayed release",68462043518,,250,$10.52 ,$10.52 ,$2.95 ,$9.63 ,$7.36 ,$8.81 ,$9.63 ,$9.63 ,$9.63 ,$3.88 ,$6.31 ,$3.16 ,$9.47 ,$7.89 ,$8.42 ,$8.73
Hoopeston Regional Hlth Center,8980250,nitroglycerin 0.4 mg sublingual tablet,68462063945,,250,$7.12 ,$7.12 ,$1.99 ,$6.51 ,$4.98 ,$5.96 ,$6.51 ,$6.51 ,$6.51 ,$2.62 ,$4.27 ,$2.14 ,$6.41 ,$5.34 ,$5.70 ,$5.91
Hoopeston Regional Hlth Center,8980250,rasagiline 0.5 mg tablet,68546014256,,250,$135.68 ,$135.68 ,$37.99 ,$124.15 ,$94.98 ,$113.56 ,$124.15 ,$124.15 ,$124.15 ,$50.00 ,$81.41 ,$40.70 ,$122.11 ,$101.76 ,$108.54 ,$112.61
Hoopeston Regional Hlth Center,8980250,"pentoxifylline ER 400 mg tablet,extended release",68682010110,,250,$4.34 ,$4.34 ,$1.22 ,$3.97 ,$3.04 ,$3.63 ,$3.97 ,$3.97 ,$3.97 ,$1.60 ,$2.60 ,$1.30 ,$3.91 ,$3.26 ,$3.47 ,$3.60
Hoopeston Regional Hlth Center,8980250,"pyridostigmine bromide ER 180 mg tablet,extended release",68682030130,,250,$95.06 ,$95.06 ,$26.62 ,$86.98 ,$66.54 ,$79.57 ,$86.98 ,$86.98 ,$86.98 ,$35.03 ,$57.04 ,$28.52 ,$85.55 ,$71.30 ,$76.05 ,$78.90
Hoopeston Regional Hlth Center,8980250,"dilTIAZem ER 120 mg capsule,24 hr,extended release",68682036790,,250,$5.81 ,$5.81 ,$1.63 ,$5.32 ,$4.07 ,$4.86 ,$5.32 ,$5.32 ,$5.32 ,$2.14 ,$3.49 ,$1.74 ,$5.23 ,$4.36 ,$4.65 ,$4.82
Hoopeston Regional Hlth Center,8980250,"dilTIAZem ER 180 mg capsule,24 hr,extended release",68682036890,,250,$6.53 ,$6.53 ,$1.83 ,$5.97 ,$4.57 ,$5.47 ,$5.97 ,$5.97 ,$5.97 ,$2.41 ,$3.92 ,$1.96 ,$5.88 ,$4.90 ,$5.22 ,$5.42
Hoopeston Regional Hlth Center,8980250,trypan blue 0.06 % intraocular syringe,68803061210,,250,$415.30 ,$415.30 ,$116.28 ,$380.00 ,$290.71 ,$347.61 ,$380.00 ,$380.00 ,$380.00 ,$153.04 ,$249.18 ,$124.59 ,$373.77 ,$311.48 ,$332.24 ,$344.70
Hoopeston Regional Hlth Center,8980250,lamoTRIgine 100 mg tablet,69097014907,,250,$24.41 ,$24.41 ,$6.83 ,$22.34 ,$17.09 ,$20.43 ,$22.34 ,$22.34 ,$22.34 ,$9.00 ,$14.65 ,$7.32 ,$21.97 ,$18.31 ,$19.53 ,$20.26
Hoopeston Regional Hlth Center,8980250,diclofenac 1 % topical gel,69097052444,,250,$254.44 ,$254.44 ,$71.24 ,$232.81 ,$178.11 ,$212.97 ,$232.81 ,$232.81 ,$232.81 ,$93.76 ,$152.66 ,$76.33 ,$229.00 ,$190.83 ,$203.55 ,$211.19
Hoopeston Regional Hlth Center,8980250,citalopram 20 mg tablet,69097082307,,250,$14.14 ,$14.14 ,$3.96 ,$12.94 ,$9.90 ,$11.84 ,$12.94 ,$12.94 ,$12.94 ,$5.21 ,$8.48 ,$4.24 ,$12.73 ,$10.61 ,$11.31 ,$11.74
Hoopeston Regional Hlth Center,8980250,tiaGABine 4 mg tablet,69238110503,,250,$35.92 ,$35.92 ,$10.06 ,$32.87 ,$25.14 ,$30.07 ,$32.87 ,$32.87 ,$32.87 ,$13.24 ,$21.55 ,$10.78 ,$32.33 ,$26.94 ,$28.74 ,$29.81
Hoopeston Regional Hlth Center,8980250,levothyroxine 25 mcg tablet,69238183001,,250,$4.37 ,$4.37 ,$1.22 ,$4.00 ,$3.06 ,$3.66 ,$4.00 ,$4.00 ,$4.00 ,$1.61 ,$2.62 ,$1.31 ,$3.93 ,$3.28 ,$3.50 ,$3.63
Hoopeston Regional Hlth Center,8980250,levothyroxine 50 mcg tablet,69238183107,,250,$4.64 ,$4.64 ,$1.30 ,$4.25 ,$3.25 ,$3.88 ,$4.25 ,$4.25 ,$4.25 ,$1.71 ,$2.78 ,$1.39 ,$4.18 ,$3.48 ,$3.71 ,$3.85
Hoopeston Regional Hlth Center,8980250,levothyroxine 75 mcg tablet,69238183201,,250,$4.88 ,$4.88 ,$1.37 ,$4.47 ,$3.42 ,$4.08 ,$4.47 ,$4.47 ,$4.47 ,$1.80 ,$2.93 ,$1.46 ,$4.39 ,$3.66 ,$3.90 ,$4.05
Hoopeston Regional Hlth Center,8980250,levothyroxine 100 mcg tablet,69238183407,,250,$4.95 ,$4.95 ,$1.39 ,$4.53 ,$3.47 ,$4.14 ,$4.53 ,$4.53 ,$4.53 ,$1.82 ,$2.97 ,$1.49 ,$4.46 ,$3.71 ,$3.96 ,$4.11
Hoopeston Regional Hlth Center,8980250,levothyroxine 112 mcg tablet,69238183501,,250,$5.36 ,$5.36 ,$1.50 ,$4.90 ,$3.75 ,$4.49 ,$4.90 ,$4.90 ,$4.90 ,$1.98 ,$3.22 ,$1.61 ,$4.82 ,$4.02 ,$4.29 ,$4.45
Hoopeston Regional Hlth Center,8980250,levothyroxine 125 mcg tablet,69238183601,,250,$5.40 ,$5.40 ,$1.51 ,$4.94 ,$3.78 ,$4.52 ,$4.94 ,$4.94 ,$4.94 ,$1.99 ,$3.24 ,$1.62 ,$4.86 ,$4.05 ,$4.32 ,$4.48
Hoopeston Regional Hlth Center,8980250,levothyroxine 175 mcg tablet,69238183901,,250,$6.09 ,$6.09 ,$1.71 ,$5.57 ,$4.26 ,$5.10 ,$5.57 ,$5.57 ,$5.57 ,$2.24 ,$3.65 ,$1.83 ,$5.48 ,$4.57 ,$4.87 ,$5.05
Hoopeston Regional Hlth Center,8980250,levothyroxine 200 mcg tablet,69238184001,,250,$6.09 ,$6.09 ,$1.71 ,$5.57 ,$4.26 ,$5.10 ,$5.57 ,$5.57 ,$5.57 ,$2.24 ,$3.65 ,$1.83 ,$5.48 ,$4.57 ,$4.87 ,$5.05
Hoopeston Regional Hlth Center,8980250,captopriL 25 mg tablet,69292052401,,250,$8.26 ,$8.26 ,$2.31 ,$7.56 ,$5.78 ,$6.91 ,$7.56 ,$7.56 ,$7.56 ,$3.04 ,$4.96 ,$2.48 ,$7.43 ,$6.20 ,$6.61 ,$6.86
Hoopeston Regional Hlth Center,8980250,flurbiprofen 0.03 % eye drops,69292072225,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,furosemide 20 mg tablet,69315011610,,250,$2.98 ,$2.98 ,$0.83 ,$2.73 ,$2.09 ,$2.49 ,$2.73 ,$2.73 ,$2.73 ,$1.10 ,$1.79 ,$0.89 ,$2.68 ,$2.24 ,$2.38 ,$2.47
Hoopeston Regional Hlth Center,8980250,folic acid 1 mg tablet,69315012710,,250,$2.70 ,$2.70 ,$0.76 ,$2.47 ,$1.89 ,$2.26 ,$2.47 ,$2.47 ,$2.47 ,$0.99 ,$1.62 ,$0.81 ,$2.43 ,$2.03 ,$2.16 ,$2.24
Hoopeston Regional Hlth Center,8980250,imipramine 10 mg tablet,69315013301,,250,$4.33 ,$4.33 ,$1.21 ,$3.96 ,$3.03 ,$3.62 ,$3.96 ,$3.96 ,$3.96 ,$1.60 ,$2.60 ,$1.30 ,$3.90 ,$3.25 ,$3.46 ,$3.59
Hoopeston Regional Hlth Center,8980250,imipramine 25 mg tablet,69315013401,,250,$5.68 ,$5.68 ,$1.59 ,$5.20 ,$3.98 ,$4.75 ,$5.20 ,$5.20 ,$5.20 ,$2.09 ,$3.41 ,$1.70 ,$5.11 ,$4.26 ,$4.54 ,$4.71
Hoopeston Regional Hlth Center,8980250,dofetilide 500 mcg capsule,69452013317,,250,$42.25 ,$42.25 ,$11.83 ,$38.66 ,$29.58 ,$35.36 ,$38.66 ,$38.66 ,$38.66 ,$15.57 ,$25.35 ,$12.68 ,$38.03 ,$31.69 ,$33.80 ,$35.07
Hoopeston Regional Hlth Center,8980250,benzonatate 100 mg capsule,69452014320,,250,$13.99 ,$13.99 ,$3.92 ,$12.80 ,$9.79 ,$11.71 ,$12.80 ,$12.80 ,$12.80 ,$5.16 ,$8.39 ,$4.20 ,$12.59 ,$10.49 ,$11.19 ,$11.61
Hoopeston Regional Hlth Center,8980250,valproic acid 250 mg capsule,69452015020,,250,$6.24 ,$6.24 ,$1.75 ,$5.71 ,$4.37 ,$5.22 ,$5.71 ,$5.71 ,$5.71 ,$2.30 ,$3.74 ,$1.87 ,$5.62 ,$4.68 ,$4.99 ,$5.18
Hoopeston Regional Hlth Center,8980250,niMODipine 30 mg capsule,69452020913,,250,$75.47 ,$75.47 ,$21.13 ,$69.06 ,$52.83 ,$63.17 ,$69.06 ,$69.06 ,$69.06 ,$27.81 ,$45.28 ,$22.64 ,$67.92 ,$56.60 ,$60.38 ,$62.64
Hoopeston Regional Hlth Center,8980250,phenylephrine 0.5 % nasal spray,69536005015,,250,$25.59 ,$25.59 ,$7.17 ,$23.41 ,$17.91 ,$21.42 ,$23.41 ,$23.41 ,$23.41 ,$9.43 ,$15.35 ,$7.68 ,$23.03 ,$19.19 ,$20.47 ,$21.24
Hoopeston Regional Hlth Center,8980250,busPIRone 10 mg tablet,69584009210,,250,$8.60 ,$8.60 ,$2.41 ,$7.87 ,$6.02 ,$7.20 ,$7.87 ,$7.87 ,$7.87 ,$3.17 ,$5.16 ,$2.58 ,$7.74 ,$6.45 ,$6.88 ,$7.14
Hoopeston Regional Hlth Center,8980250,methocarbamoL 500 mg tablet,70010075405,,250,$4.58 ,$4.58 ,$1.28 ,$4.19 ,$3.21 ,$3.83 ,$4.19 ,$4.19 ,$4.19 ,$1.69 ,$2.75 ,$1.37 ,$4.12 ,$3.44 ,$3.66 ,$3.80
Hoopeston Regional Hlth Center,8980250,methocarbamoL 750 mg tablet,70010077005,,250,$5.55 ,$5.55 ,$1.55 ,$5.08 ,$3.89 ,$4.65 ,$5.08 ,$5.08 ,$5.08 ,$2.05 ,$3.33 ,$1.67 ,$5.00 ,$4.16 ,$4.44 ,$4.61
Hoopeston Regional Hlth Center,8980250,brimonidine 0.2 % eye drops,70069023101,,250,$152.50 ,$152.50 ,$42.70 ,$139.54 ,$106.75 ,$127.64 ,$139.54 ,$139.54 ,$139.54 ,$56.20 ,$91.50 ,$45.75 ,$137.25 ,$114.38 ,$122.00 ,$126.58
Hoopeston Regional Hlth Center,8980250,sodium nitroprusside 25 mg/mL intravenous solution,70069026101,J3490,250,$180.45 ,$180.45 ,$50.53 ,$165.11 ,$126.32 ,$151.04 ,$165.11 ,$165.11 ,$165.11 ,$66.50 ,$108.27 ,$54.14 ,$162.41 ,$135.34 ,$144.36 ,$149.77
Hoopeston Regional Hlth Center,8980250,lactose-reduced food with fiber 0.06 gram-1.2 kcal/mL oral liquid,70074062684,,250,$44.24 ,$44.24 ,$12.39 ,$40.48 ,$30.97 ,$37.03 ,$40.48 ,$40.48 ,$40.48 ,$16.30 ,$26.54 ,$13.27 ,$39.82 ,$33.18 ,$35.39 ,$36.72
Hoopeston Regional Hlth Center,8980250,nutritional supplements 0.06 gram-1 kcal/mL oral liquid,70074062702,,250,$38.42 ,$38.42 ,$10.76 ,$35.15 ,$26.89 ,$32.16 ,$35.15 ,$35.15 ,$35.15 ,$14.16 ,$23.05 ,$11.53 ,$34.58 ,$28.82 ,$30.74 ,$31.89
Hoopeston Regional Hlth Center,8980250,nutritional supplement-fiber 0.06 gram-1 kcal/mL oral liquid,70074062704,,250,$38.42 ,$38.42 ,$10.76 ,$35.15 ,$26.89 ,$32.16 ,$35.15 ,$35.15 ,$35.15 ,$14.16 ,$23.05 ,$11.53 ,$34.58 ,$28.82 ,$30.74 ,$31.89
Hoopeston Regional Hlth Center,8980250,cannabidioL 100 mg/mL oral solution,70127010010,,250,"$5,974.49 ","$5,974.49 ","$1,672.86 ","$5,466.66 ","$4,182.14 ","$5,000.65 ","$5,466.66 ","$5,466.66 ","$5,466.66 ","$2,201.60 ","$3,584.69 ","$1,792.35 ","$5,377.04 ","$4,480.87 ","$4,779.59 ","$4,958.83 "
Hoopeston Regional Hlth Center,8980250,aliskiren 300 mg tablet,70839030030,,250,$51.35 ,$51.35 ,$14.38 ,$46.99 ,$35.95 ,$42.98 ,$46.99 ,$46.99 ,$46.99 ,$18.92 ,$30.81 ,$15.41 ,$46.22 ,$38.51 ,$41.08 ,$42.62
Hoopeston Regional Hlth Center,8980250,"tranexamic acid 1,000 mg/10 mL (100 mg/mL) intravenous solution",70860040010,,250,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980250,potassium iodide 1 gram/mL oral solution,71740011230,,250,"$2,222.82 ","$2,222.82 ",$622.39 ,"$2,033.88 ","$1,555.97 ","$1,860.50 ","$2,033.88 ","$2,033.88 ","$2,033.88 ",$819.11 ,"$1,333.69 ",$666.85 ,"$2,000.54 ","$1,667.12 ","$1,778.26 ","$1,844.94 "
Hoopeston Regional Hlth Center,8980250,white petrolatum 41 % topical ointment,72140003147,,250,$100.32 ,$100.32 ,$28.09 ,$91.79 ,$70.22 ,$83.97 ,$91.79 ,$91.79 ,$91.79 ,$36.97 ,$60.19 ,$30.10 ,$90.29 ,$75.24 ,$80.26 ,$83.27
Hoopeston Regional Hlth Center,8980250,verapamiL 2.5 mg/mL intravenous solution,72485010825,J3490,250,$76.10 ,$76.10 ,$21.31 ,$69.63 ,$53.27 ,$63.70 ,$69.63 ,$69.63 ,$69.63 ,$28.04 ,$45.66 ,$22.83 ,$68.49 ,$57.08 ,$60.88 ,$63.16
Hoopeston Regional Hlth Center,8980250,verapamiL 2.5 mg/mL intravenous solution,72485010905,J3490,250,$126.67 ,$126.67 ,$35.47 ,$115.90 ,$88.67 ,$106.02 ,$115.90 ,$115.90 ,$115.90 ,$46.68 ,$76.00 ,$38.00 ,$114.00 ,$95.00 ,$101.34 ,$105.14
Hoopeston Regional Hlth Center,8980250,sotaloL 120 mg tablet,76385011501,,250,$18.26 ,$18.26 ,$5.11 ,$16.71 ,$12.78 ,$15.28 ,$16.71 ,$16.71 ,$16.71 ,$6.73 ,$10.96 ,$5.48 ,$16.43 ,$13.70 ,$14.61 ,$15.16
Hoopeston Regional Hlth Center,8980250,zinc sulfate 50 mg zinc (220 mg) capsule,77333098310,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,phenoL 1.4 % mucosal aerosol spray,78112001103,,250,$32.34 ,$32.34 ,$9.06 ,$29.59 ,$22.64 ,$27.07 ,$29.59 ,$29.59 ,$29.59 ,$11.92 ,$19.40 ,$9.70 ,$29.11 ,$24.26 ,$25.87 ,$26.84
Hoopeston Regional Hlth Center,8980250,sodium hyaluronate 10 mg/mL intraocular syringe,85446036971,,250,$542.14 ,$542.14 ,$151.80 ,$496.06 ,$379.50 ,$453.77 ,$496.06 ,$496.06 ,$496.06 ,$199.78 ,$325.28 ,$162.64 ,$487.93 ,$406.61 ,$433.71 ,$449.98
Hoopeston Regional Hlth Center,8980250,"thiamine mononitrate 100 mg tablet,thiamine HCL 100 mg tablet",87701040729,,250,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980250,sodium chloride 0.65 % nasal spray aerosol,87701055205,,250,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980250,sulfamethoxazole 200 mg-trimethoprim 40 mg/5 mL oral suspension,9999042960,,250,$20.67 ,$20.67 ,$5.79 ,$18.91 ,$14.47 ,$17.30 ,$18.91 ,$18.91 ,$18.91 ,$7.62 ,$12.40 ,$6.20 ,$18.60 ,$15.50 ,$16.54 ,$17.16
Hoopeston Regional Hlth Center,8980255,iothalamate meglumine 60 % injection solution,19095313,Q9961,255,$116.89 ,$116.89 ,$32.73 ,$106.95 ,$81.82 ,$97.84 ,$106.95 ,$106.95 ,$106.95 ,$43.07 ,$70.13 ,$35.07 ,$105.20 ,$87.67 ,$93.51 ,$97.02
Hoopeston Regional Hlth Center,8980255,iothalamate meglumine 43 % intravenous solution,19318309,Q9960,255,$697.44 ,$697.44 ,$195.28 ,$638.16 ,$488.21 ,$583.76 ,$638.16 ,$638.16 ,$638.16 ,$257.01 ,$418.46 ,$209.23 ,$627.70 ,$523.08 ,$557.95 ,$578.88
Hoopeston Regional Hlth Center,8980255,diatrizoate meglumine-diatrizoate sodium 66 %-10 % oral solution,270044540,Q9963,255,$148.49 ,$148.49 ,$41.58 ,$135.87 ,$103.94 ,$124.29 ,$135.87 ,$135.87 ,$135.87 ,$54.72 ,$89.09 ,$44.55 ,$133.64 ,$111.37 ,$118.79 ,$123.25
Hoopeston Regional Hlth Center,8980255,iopamidoL 61 % intravenous solution,270131530,Q9967,255,$160.83 ,$160.83 ,$45.03 ,$147.16 ,$112.58 ,$134.61 ,$147.16 ,$147.16 ,$147.16 ,$59.27 ,$96.50 ,$48.25 ,$144.75 ,$120.62 ,$128.66 ,$133.49
Hoopeston Regional Hlth Center,8980255,iopamidoL 61 % intravenous solution,270131535,Q9967,255,$157.19 ,$157.19 ,$44.01 ,$143.83 ,$110.03 ,$131.57 ,$143.83 ,$143.83 ,$143.83 ,$57.92 ,$94.31 ,$47.16 ,$141.47 ,$117.89 ,$125.75 ,$130.47
Hoopeston Regional Hlth Center,8980255,iopamidoL 41 % intrathecal solution,270141111,Q9966,255,$680.41 ,$680.41 ,$190.51 ,$622.58 ,$476.29 ,$569.50 ,$622.58 ,$622.58 ,$622.58 ,$250.73 ,$408.25 ,$204.12 ,$612.37 ,$510.31 ,$544.33 ,$564.74
Hoopeston Regional Hlth Center,8980255,iopamidoL 61 % intrathecal solution,270141215,Q9967,255,$403.23 ,$403.23 ,$112.90 ,$368.96 ,$282.26 ,$337.50 ,$368.96 ,$368.96 ,$368.96 ,$148.59 ,$241.94 ,$120.97 ,$362.91 ,$302.42 ,$322.58 ,$334.68
Hoopeston Regional Hlth Center,8980255,iohexoL 300 mg iodine/mL intravenous solution,407141351,Q9967,255,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980255,iohexoL 300 mg iodine/mL intravenous solution,407141360,Q9967,255,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980255,iohexoL 300 mg iodine/mL intravenous solution,407141366,Q9967,255,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980255,barium sulfate 2 % (w/v) oral suspension,32909074103,,255,$19.81 ,$19.81 ,$5.55 ,$18.13 ,$13.87 ,$16.58 ,$18.13 ,$18.13 ,$18.13 ,$7.30 ,$11.89 ,$5.94 ,$17.83 ,$14.86 ,$15.85 ,$16.44
Hoopeston Regional Hlth Center,8980255,gadopentetate dimeglumine 10 mmol/20 mL(469.01 mg/mL) intravenous soln,50419018884,A9579,255,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980255,gadobutroL 7.5 mmol/7.5 mL (1 mmol/mL) intravenous solution,50419032511,A9585,255,$438.15 ,$438.15 ,$122.68 ,$400.91 ,$306.71 ,$366.73 ,$400.91 ,$400.91 ,$400.91 ,$161.46 ,$262.89 ,$131.45 ,$394.34 ,$328.61 ,$350.52 ,$363.66
Hoopeston Regional Hlth Center,9030003,PUMP SET W/O FILTER,,,258,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,8980258,potassium chloride 20 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,264763500,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 20 mEq/L in D5-0.9 % sodium chloride intravenous,264765200,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 20 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,338067104,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,sodium chloride 0.9 % irrigation solution,409613803,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 20 mEq/L in D5-0.9 % sodium chloride intravenous,409710709,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 40 mEq/L in D5-0.9 % sodium chloride intravenous,409710909,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 20 mEq/L-lactated ringers-5 % dextrose intravenous,409711109,J7120,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,sodium chloride 0.9 % irrigation solution,409713809,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 20 mEq/L in dextrose 5 %-0.2 % sodium chloride IV,409790109,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 20 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,409790209,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 30 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,409790309,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 40 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,409790409,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,dextrose 5 %-0.9 % sodium chloride IV,409794109,J7042,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980258,potassium chloride 10 mEq/L in dextrose 5 %-0.45 % sodium chloride IV,409799309,,258,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980259,entecavir 0.5 mg tablet,3161112,,259,$200.30 ,$200.30 ,$56.08 ,$183.27 ,$140.21 ,$167.65 ,$183.27 ,$183.27 ,$183.27 ,$73.81 ,$120.18 ,$60.09 ,$180.27 ,$150.23 ,$160.24 ,$166.25
Hoopeston Regional Hlth Center,8980259,stavudine 30 mg capsule,3196601,,259,$39.83 ,$39.83 ,$11.15 ,$36.44 ,$27.88 ,$33.34 ,$36.44 ,$36.44 ,$36.44 ,$14.68 ,$23.90 ,$11.95 ,$35.85 ,$29.87 ,$31.86 ,$33.06
Hoopeston Regional Hlth Center,8980259,stavudine 40 mg capsule,3196701,,259,$40.42 ,$40.42 ,$11.32 ,$36.98 ,$28.29 ,$33.83 ,$36.98 ,$36.98 ,$36.98 ,$14.89 ,$24.25 ,$12.13 ,$36.38 ,$30.32 ,$32.34 ,$33.55
Hoopeston Regional Hlth Center,8980259,ibandronate 150 mg tablet,4018682,,259,$810.13 ,$810.13 ,$226.84 ,$741.27 ,$567.09 ,$678.08 ,$741.27 ,$741.27 ,$741.27 ,$298.53 ,$486.08 ,$243.04 ,$729.12 ,$607.60 ,$648.10 ,$672.41
Hoopeston Regional Hlth Center,8980259,alcaftadine 0.25 % eye drops,23429003,,259,$22.41 ,$22.41 ,$6.27 ,$20.51 ,$15.69 ,$18.76 ,$20.51 ,$20.51 ,$20.51 ,$8.26 ,$13.45 ,$6.72 ,$20.17 ,$16.81 ,$17.93 ,$18.60
Hoopeston Regional Hlth Center,8980259,oxybutynin 3.9 mg/24 hr semiweekly transdermal patch,23615308,,259,$365.07 ,$365.07 ,$102.22 ,$334.04 ,$255.55 ,$305.56 ,$334.04 ,$334.04 ,$334.04 ,$134.53 ,$219.04 ,$109.52 ,$328.56 ,$273.80 ,$292.06 ,$303.01
Hoopeston Regional Hlth Center,8980259,"diclofenac 50 mg-misoprostoL 200 mcg tablet,immed.and delayed release",25141160,,259,$42.79 ,$42.79 ,$11.98 ,$39.15 ,$29.95 ,$35.82 ,$39.15 ,$39.15 ,$39.15 ,$15.77 ,$25.67 ,$12.84 ,$38.51 ,$32.09 ,$34.23 ,$35.52
Hoopeston Regional Hlth Center,8980259,penicillAMINE 250 mg tablet,37440101,,259,$281.31 ,$281.31 ,$78.77 ,$257.40 ,$196.92 ,$235.46 ,$257.40 ,$257.40 ,$257.40 ,$103.66 ,$168.79 ,$84.39 ,$253.18 ,$210.98 ,$225.05 ,$233.49
Hoopeston Regional Hlth Center,8980259,hydrocortisone acetate 10 % (80 mg) rectal foam,37683015,,259,"$2,247.70 ","$2,247.70 ",$629.36 ,"$2,056.65 ","$1,573.39 ","$1,881.32 ","$2,056.65 ","$2,056.65 ","$2,056.65 ",$828.28 ,"$1,348.62 ",$674.31 ,"$2,022.93 ","$1,685.78 ","$1,798.16 ","$1,865.59 "
Hoopeston Regional Hlth Center,8980259,eletriptan 20 mg tablet,49233045,,259,$295.98 ,$295.98 ,$82.87 ,$270.82 ,$207.19 ,$247.74 ,$270.82 ,$270.82 ,$270.82 ,$109.07 ,$177.59 ,$88.79 ,$266.38 ,$221.99 ,$236.78 ,$245.66
Hoopeston Regional Hlth Center,8980259,eletriptan 40 mg tablet,49234045,,259,$295.98 ,$295.98 ,$82.87 ,$270.82 ,$207.19 ,$247.74 ,$270.82 ,$270.82 ,$270.82 ,$109.07 ,$177.59 ,$88.79 ,$266.38 ,$221.99 ,$236.78 ,$245.66
Hoopeston Regional Hlth Center,8980259,voriconazole 50 mg tablet,49317030,,259,$10.53 ,$10.53 ,$2.95 ,$9.63 ,$7.37 ,$8.81 ,$9.63 ,$9.63 ,$9.63 ,$3.88 ,$6.32 ,$3.16 ,$9.48 ,$7.90 ,$8.42 ,$8.74
Hoopeston Regional Hlth Center,8980259,testosterone 1 % (50 mg/5 gram) transdermal gel packet,51845030,,259,$100.14 ,$100.14 ,$28.04 ,$91.63 ,$70.10 ,$83.82 ,$91.63 ,$91.63 ,$91.63 ,$36.90 ,$60.08 ,$30.04 ,$90.13 ,$75.11 ,$80.11 ,$83.12
Hoopeston Regional Hlth Center,8980259,digoxin 50 mcg/mL (0.05 mg/mL) oral solution,54005746,,259,$55.88 ,$55.88 ,$15.65 ,$51.13 ,$39.12 ,$46.77 ,$51.13 ,$51.13 ,$51.13 ,$20.59 ,$33.53 ,$16.76 ,$50.29 ,$41.91 ,$44.70 ,$46.38
Hoopeston Regional Hlth Center,8980259,risperiDONE 1 mg/mL oral solution,54006344,,259,$39.52 ,$39.52 ,$11.07 ,$36.16 ,$27.66 ,$33.08 ,$36.16 ,$36.16 ,$36.16 ,$14.56 ,$23.71 ,$11.86 ,$35.57 ,$29.64 ,$31.62 ,$32.80
Hoopeston Regional Hlth Center,8980259,acarbose 50 mg tablet,54014125,,259,$6.89 ,$6.89 ,$1.93 ,$6.30 ,$4.82 ,$5.77 ,$6.30 ,$6.30 ,$6.30 ,$2.54 ,$4.13 ,$2.07 ,$6.20 ,$5.17 ,$5.51 ,$5.72
Hoopeston Regional Hlth Center,8980259,morphine 30 mg immediate release tablet,54023624,,259,$11.86 ,$11.86 ,$3.32 ,$10.85 ,$8.30 ,$9.93 ,$10.85 ,$10.85 ,$10.85 ,$4.37 ,$7.12 ,$3.56 ,$10.67 ,$8.90 ,$9.49 ,$9.84
Hoopeston Regional Hlth Center,8980259,furosemide 10 mg/mL oral solution,54329446,,259,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980259,meperidine 50 mg/5 mL oral solution,54354563,,259,$16.30 ,$16.30 ,$4.56 ,$14.91 ,$11.41 ,$13.64 ,$14.91 ,$14.91 ,$14.91 ,$6.01 ,$9.78 ,$4.89 ,$14.67 ,$12.23 ,$13.04 ,$13.53
Hoopeston Regional Hlth Center,8980259,midazolam 2 mg/mL oral syrup,54356699,,259,$68.65 ,$68.65 ,$19.22 ,$62.81 ,$48.06 ,$57.46 ,$62.81 ,$62.81 ,$62.81 ,$25.30 ,$41.19 ,$20.60 ,$61.79 ,$51.49 ,$54.92 ,$56.98
Hoopeston Regional Hlth Center,8980259,naphazoline 0.025 %-pheniramine 0.3 % eye drops,65008515,,259,$55.97 ,$55.97 ,$15.67 ,$51.21 ,$39.18 ,$46.85 ,$51.21 ,$51.21 ,$51.21 ,$20.62 ,$33.58 ,$16.79 ,$50.37 ,$41.98 ,$44.78 ,$46.46
Hoopeston Regional Hlth Center,8980259,olopatadine 0.1 % eye drops,65027105,,259,"$1,646.05 ","$1,646.05 ",$460.89 ,"$1,506.14 ","$1,152.24 ","$1,377.74 ","$1,506.14 ","$1,506.14 ","$1,506.14 ",$606.57 ,$987.63 ,$493.82 ,"$1,481.45 ","$1,234.54 ","$1,316.84 ","$1,366.22 "
Hoopeston Regional Hlth Center,8980259,peg 400-propylene glycol 0.4 %-0.3 % eye drops,65042915,,259,$66.09 ,$66.09 ,$18.51 ,$60.47 ,$46.26 ,$55.32 ,$60.47 ,$60.47 ,$60.47 ,$24.35 ,$39.65 ,$19.83 ,$59.48 ,$49.57 ,$52.87 ,$54.85
Hoopeston Regional Hlth Center,8980259,tobramycin-dexamethasone 0.3 %-0.1 % eye ointment,65064835,,259,"$1,137.60 ","$1,137.60 ",$318.53 ,"$1,040.90 ",$796.32 ,$952.17 ,"$1,040.90 ","$1,040.90 ","$1,040.90 ",$419.21 ,$682.56 ,$341.28 ,"$1,023.84 ",$853.20 ,$910.08 ,$944.21
Hoopeston Regional Hlth Center,8980259,phenelzine 15 mg tablet,71035060,,259,$15.91 ,$15.91 ,$4.45 ,$14.56 ,$11.14 ,$13.32 ,$14.56 ,$14.56 ,$14.56 ,$5.86 ,$9.55 ,$4.77 ,$14.32 ,$11.93 ,$12.73 ,$13.21
Hoopeston Regional Hlth Center,8980259,phenytoin sodium extended 30 mg capsule,71374066,,259,$9.21 ,$9.21 ,$2.58 ,$8.43 ,$6.45 ,$7.71 ,$8.43 ,$8.43 ,$8.43 ,$3.39 ,$5.53 ,$2.76 ,$8.29 ,$6.91 ,$7.37 ,$7.64
Hoopeston Regional Hlth Center,8980259,nateglinide 60 mg tablet,78035105,,259,$22.45 ,$22.45 ,$6.29 ,$20.54 ,$15.72 ,$18.79 ,$20.54 ,$20.54 ,$20.54 ,$8.27 ,$13.47 ,$6.74 ,$20.21 ,$16.84 ,$17.96 ,$18.63
Hoopeston Regional Hlth Center,8980259,nateglinide 120 mg tablet,78035205,,259,$23.24 ,$23.24 ,$6.51 ,$21.26 ,$16.27 ,$19.45 ,$21.26 ,$21.26 ,$21.26 ,$8.56 ,$13.94 ,$6.97 ,$20.92 ,$17.43 ,$18.59 ,$19.29
Hoopeston Regional Hlth Center,8980259,"carBAMazepine ER 100 mg tablet,extended release,12 hr",78051005,,259,$9.92 ,$9.92 ,$2.78 ,$9.08 ,$6.94 ,$8.30 ,$9.08 ,$9.08 ,$9.08 ,$3.66 ,$5.95 ,$2.98 ,$8.93 ,$7.44 ,$7.94 ,$8.23
Hoopeston Regional Hlth Center,8980259,nitroglycerin 0.8 mg/hr transdermal 24 hour patch,85081935,,259,$33.48 ,$33.48 ,$9.37 ,$30.63 ,$23.44 ,$28.02 ,$30.63 ,$30.63 ,$30.63 ,$12.34 ,$20.09 ,$10.04 ,$30.13 ,$25.11 ,$26.78 ,$27.79
Hoopeston Regional Hlth Center,8980259,moexipriL 7.5 mg tablet,93001701,,259,$8.80 ,$8.80 ,$2.46 ,$8.05 ,$6.16 ,$7.37 ,$8.05 ,$8.05 ,$8.05 ,$3.24 ,$5.28 ,$2.64 ,$7.92 ,$6.60 ,$7.04 ,$7.30
Hoopeston Regional Hlth Center,8980259,nefazodone 100 mg tablet,93102406,,259,$24.69 ,$24.69 ,$6.91 ,$22.59 ,$17.28 ,$20.67 ,$22.59 ,$22.59 ,$22.59 ,$9.10 ,$14.81 ,$7.41 ,$22.22 ,$18.52 ,$19.75 ,$20.49
Hoopeston Regional Hlth Center,8980259,dicloxacillin 250 mg capsule,93312301,,259,$8.75 ,$8.75 ,$2.45 ,$8.01 ,$6.13 ,$7.32 ,$8.01 ,$8.01 ,$8.01 ,$3.22 ,$5.25 ,$2.63 ,$7.88 ,$6.56 ,$7.00 ,$7.26
Hoopeston Regional Hlth Center,8980259,dicloxacillin 500 mg capsule,93312501,,259,$14.01 ,$14.01 ,$3.92 ,$12.82 ,$9.81 ,$11.73 ,$12.82 ,$12.82 ,$12.82 ,$5.16 ,$8.41 ,$4.20 ,$12.61 ,$10.51 ,$11.21 ,$11.63
Hoopeston Regional Hlth Center,8980259,moexipriL 15 mg tablet,93515001,,259,$9.11 ,$9.11 ,$2.55 ,$8.34 ,$6.38 ,$7.63 ,$8.34 ,$8.34 ,$8.34 ,$3.36 ,$5.47 ,$2.73 ,$8.20 ,$6.83 ,$7.29 ,$7.56
Hoopeston Regional Hlth Center,8980259,nefazodone 150 mg tablet,93711306,,259,$25.12 ,$25.12 ,$7.03 ,$22.98 ,$17.58 ,$21.03 ,$22.98 ,$22.98 ,$22.98 ,$9.26 ,$15.07 ,$7.54 ,$22.61 ,$18.84 ,$20.10 ,$20.85
Hoopeston Regional Hlth Center,8980259,"metFORMIN ER 500 mg tablet,extended release 24 hr",93726701,,259,$7.12 ,$7.12 ,$1.99 ,$6.51 ,$4.98 ,$5.96 ,$6.51 ,$6.51 ,$6.51 ,$2.62 ,$4.27 ,$2.14 ,$6.41 ,$5.34 ,$5.70 ,$5.91
Hoopeston Regional Hlth Center,8980259,famciclovir 500 mg tablet,93811956,,259,$52.58 ,$52.58 ,$14.72 ,$48.11 ,$36.81 ,$44.01 ,$48.11 ,$48.11 ,$48.11 ,$19.38 ,$31.55 ,$15.77 ,$47.32 ,$39.44 ,$42.06 ,$43.64
Hoopeston Regional Hlth Center,8980259,lactulose 20 gram/30 mL Oral Soln,121115400,,259,$6.10 ,$6.10 ,$1.71 ,$5.58 ,$4.27 ,$5.11 ,$5.58 ,$5.58 ,$5.58 ,$2.25 ,$3.66 ,$1.83 ,$5.49 ,$4.58 ,$4.88 ,$5.06
Hoopeston Regional Hlth Center,8980259,potassium chloride 20 mEq/15 mL oral liquid,121146515,,259,$27.56 ,$27.56 ,$7.72 ,$25.22 ,$19.29 ,$23.07 ,$25.22 ,$25.22 ,$25.22 ,$10.16 ,$16.54 ,$8.27 ,$24.80 ,$20.67 ,$22.05 ,$22.87
Hoopeston Regional Hlth Center,8980259,mineral oil enema,132030140,,259,$2.98 ,$2.98 ,$0.83 ,$2.73 ,$2.09 ,$2.49 ,$2.73 ,$2.73 ,$2.73 ,$1.10 ,$1.79 ,$0.89 ,$2.68 ,$2.24 ,$2.38 ,$2.47
Hoopeston Regional Hlth Center,8980259,docosanoL 10 % topical cream,135020001,,259,$107.41 ,$107.41 ,$30.07 ,$98.28 ,$75.19 ,$89.90 ,$98.28 ,$98.28 ,$98.28 ,$39.58 ,$64.45 ,$32.22 ,$96.67 ,$80.56 ,$85.93 ,$89.15
Hoopeston Regional Hlth Center,8980259,digoxin 250 mcg (0.25 mg) tablet,143124101,,259,$13.05 ,$13.05 ,$3.65 ,$11.94 ,$9.14 ,$10.92 ,$11.94 ,$11.94 ,$11.94 ,$4.81 ,$7.83 ,$3.92 ,$11.75 ,$9.79 ,$10.44 ,$10.83
Hoopeston Regional Hlth Center,8980259,Insulin Regular human 100 unit/mL Sub-Q,169183311,,259,$965.10 ,$965.10 ,$270.23 ,$883.07 ,$675.57 ,$807.79 ,$883.07 ,$883.07 ,$883.07 ,$355.64 ,$579.06 ,$289.53 ,$868.59 ,$723.83 ,$772.08 ,$801.03
Hoopeston Regional Hlth Center,8980259,"buPROPion HCL SR 150 mg tablet,12 hr sustained-release",173013555,,259,$39.32 ,$39.32 ,$11.01 ,$35.98 ,$27.52 ,$32.91 ,$35.98 ,$35.98 ,$35.98 ,$14.49 ,$23.59 ,$11.80 ,$35.39 ,$29.49 ,$31.46 ,$32.64
Hoopeston Regional Hlth Center,8980259,salmeteroL 50 mcg/dose blister powder for inhalation,173052000,,259,"$1,793.11 ","$1,793.11 ",$502.07 ,"$1,640.70 ","$1,255.18 ","$1,500.83 ","$1,640.70 ","$1,640.70 ","$1,640.70 ",$660.76 ,"$1,075.87 ",$537.93 ,"$1,613.80 ","$1,344.83 ","$1,434.49 ","$1,488.28 "
Hoopeston Regional Hlth Center,8980259,lamoTRIgine 200 mg tablet,173064460,,259,$87.22 ,$87.22 ,$24.42 ,$79.81 ,$61.05 ,$73.00 ,$79.81 ,$79.81 ,$79.81 ,$32.14 ,$52.33 ,$26.17 ,$78.50 ,$65.42 ,$69.78 ,$72.39
Hoopeston Regional Hlth Center,8980259,fluticasone 500 mcg-salmeteroL 50 mcg/dose blistr powdr for inhalation,173069704,,259,"$1,676.47 ","$1,676.47 ",$469.41 ,"$1,533.97 ","$1,173.53 ","$1,403.21 ","$1,533.97 ","$1,533.97 ","$1,533.97 ",$617.78 ,"$1,005.88 ",$502.94 ,"$1,508.82 ","$1,257.35 ","$1,341.18 ","$1,391.47 "
Hoopeston Regional Hlth Center,8980259,quiNIDine sulfate 200 mg tablet,185434601,,259,$3.77 ,$3.77 ,$1.06 ,$3.45 ,$2.64 ,$3.16 ,$3.45 ,$3.45 ,$3.45 ,$1.39 ,$2.26 ,$1.13 ,$3.39 ,$2.83 ,$3.02 ,$3.13
Hoopeston Regional Hlth Center,8980259,dihydroergotamine 0.5 mg/pump act. (4 mg/mL) nasal spray,187024503,,259,"$2,693.20 ","$2,693.20 ",$754.10 ,"$2,464.28 ","$1,885.24 ","$2,254.21 ","$2,464.28 ","$2,464.28 ","$2,464.28 ",$992.44 ,"$1,615.92 ",$807.96 ,"$2,423.88 ","$2,019.90 ","$2,154.56 ","$2,235.36 "
Hoopeston Regional Hlth Center,8980259,phytonadione (vitamin K1) 5 mg tablet,187170405,,259,$254.94 ,$254.94 ,$71.38 ,$233.27 ,$178.46 ,$213.38 ,$233.27 ,$233.27 ,$233.27 ,$93.95 ,$152.96 ,$76.48 ,$229.45 ,$191.21 ,$203.95 ,$211.60
Hoopeston Regional Hlth Center,8980259,magnesium carbonate 54 mg/5 mL oral liquid,187526701,,259,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980259,sodium chloride-aloe vera nasal gel,225052547,,259,$20.32 ,$20.32 ,$5.69 ,$18.59 ,$14.22 ,$17.01 ,$18.59 ,$18.59 ,$18.59 ,$7.49 ,$12.19 ,$6.10 ,$18.29 ,$15.24 ,$16.26 ,$16.87
Hoopeston Regional Hlth Center,8980259,niCARdipine 20 mg capsule,378102077,,259,$12.72 ,$12.72 ,$3.56 ,$11.64 ,$8.90 ,$10.65 ,$11.64 ,$11.64 ,$11.64 ,$4.69 ,$7.63 ,$3.82 ,$11.45 ,$9.54 ,$10.18 ,$10.56
Hoopeston Regional Hlth Center,8980259,acebutoloL 400 mg capsule,378140001,,259,$8.57 ,$8.57 ,$2.40 ,$7.84 ,$6.00 ,$7.17 ,$7.84 ,$7.84 ,$7.84 ,$3.16 ,$5.14 ,$2.57 ,$7.71 ,$6.43 ,$6.86 ,$7.11
Hoopeston Regional Hlth Center,8980259,niCARdipine 30 mg capsule,378143077,,259,$17.20 ,$17.20 ,$4.82 ,$15.74 ,$12.04 ,$14.40 ,$15.74 ,$15.74 ,$15.74 ,$6.34 ,$10.32 ,$5.16 ,$15.48 ,$12.90 ,$13.76 ,$14.28
Hoopeston Regional Hlth Center,8980259,"omeprazole 10 mg capsule,delayed release",378521193,,259,$19.57 ,$19.57 ,$5.48 ,$17.91 ,$13.70 ,$16.38 ,$17.91 ,$17.91 ,$17.91 ,$7.21 ,$11.74 ,$5.87 ,$17.61 ,$14.68 ,$15.66 ,$16.24
Hoopeston Regional Hlth Center,8980259,eprosartan 600 mg tablet,378662993,,259,$18.30 ,$18.30 ,$5.12 ,$16.74 ,$12.81 ,$15.32 ,$16.74 ,$16.74 ,$16.74 ,$6.74 ,$10.98 ,$5.49 ,$16.47 ,$13.73 ,$14.64 ,$15.19
Hoopeston Regional Hlth Center,8980259,sodium chloride 3 % for nebulization,378699789,J3490,259,$6.52 ,$6.52 ,$1.83 ,$5.97 ,$4.56 ,$5.46 ,$5.97 ,$5.97 ,$5.97 ,$2.40 ,$3.91 ,$1.96 ,$5.87 ,$4.89 ,$5.22 ,$5.41
Hoopeston Regional Hlth Center,8980259,gentian violet 1 % topical solution,395100392,,259,$51.23 ,$51.23 ,$14.34 ,$46.88 ,$35.86 ,$42.88 ,$46.88 ,$46.88 ,$46.88 ,$18.88 ,$30.74 ,$15.37 ,$46.11 ,$38.42 ,$40.98 ,$42.52
Hoopeston Regional Hlth Center,8980259,methylphenidate 20 mg tablet,406114601,,259,$11.64 ,$11.64 ,$3.26 ,$10.65 ,$8.15 ,$9.74 ,$10.65 ,$10.65 ,$10.65 ,$4.29 ,$6.98 ,$3.49 ,$10.48 ,$8.73 ,$9.31 ,$9.66
Hoopeston Regional Hlth Center,8980259,"morphine ER 60 mg tablet,extended release",406838062,,259,$29.12 ,$29.12 ,$8.15 ,$26.64 ,$20.38 ,$24.37 ,$26.64 ,$26.64 ,$26.64 ,$10.73 ,$17.47 ,$8.74 ,$26.21 ,$21.84 ,$23.30 ,$24.17
Hoopeston Regional Hlth Center,8980259,tetracaine 2 % topical solution,409186601,,259,$110.16 ,$110.16 ,$30.84 ,$100.80 ,$77.11 ,$92.20 ,$100.80 ,$100.80 ,$100.80 ,$40.59 ,$66.10 ,$33.05 ,$99.14 ,$82.62 ,$88.13 ,$91.43
Hoopeston Regional Hlth Center,8980259,sodium chloride 2.5 mEq/mL intravenous solution,409666075,,259,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980259,risedronate 5 mg tablet,430047115,,259,$59.33 ,$59.33 ,$16.61 ,$54.29 ,$41.53 ,$49.66 ,$54.29 ,$54.29 ,$54.29 ,$21.86 ,$35.60 ,$17.80 ,$53.40 ,$44.50 ,$47.46 ,$49.24
Hoopeston Regional Hlth Center,8980259,risedronate 35 mg tablet,430047203,,259,$366.18 ,$366.18 ,$102.53 ,$335.05 ,$256.33 ,$306.49 ,$335.05 ,$335.05 ,$335.05 ,$134.94 ,$219.71 ,$109.85 ,$329.56 ,$274.64 ,$292.94 ,$303.93
Hoopeston Regional Hlth Center,8980259,thyroid (pork) 30 mg tablet,456045801,,259,$6.98 ,$6.98 ,$1.95 ,$6.39 ,$4.89 ,$5.84 ,$6.39 ,$6.39 ,$6.39 ,$2.57 ,$4.19 ,$2.09 ,$6.28 ,$5.24 ,$5.58 ,$5.79
Hoopeston Regional Hlth Center,8980259,digoxin 250 mcg (0.25 mg) tablet,527132510,,259,$11.19 ,$11.19 ,$3.13 ,$10.24 ,$7.83 ,$9.37 ,$10.24 ,$10.24 ,$10.24 ,$4.12 ,$6.71 ,$3.36 ,$10.07 ,$8.39 ,$8.95 ,$9.29
Hoopeston Regional Hlth Center,8980259,niacin 100 mg tablet,536407601,,259,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980259,flavoxATE 100 mg tablet,574011501,,259,$9.15 ,$9.15 ,$2.56 ,$8.37 ,$6.41 ,$7.66 ,$8.37 ,$8.37 ,$8.37 ,$3.37 ,$5.49 ,$2.75 ,$8.24 ,$6.86 ,$7.32 ,$7.59
Hoopeston Regional Hlth Center,8980259,bacitracin 500 unit/gram eye ointment,574402235,,259,$503.91 ,$503.91 ,$141.09 ,$461.08 ,$352.74 ,$421.77 ,$461.08 ,$461.08 ,$461.08 ,$185.69 ,$302.35 ,$151.17 ,$453.52 ,$377.93 ,$403.13 ,$418.25
Hoopeston Regional Hlth Center,8980259,aspirin 600 mg rectal suppository,574703612,,259,$2.11 ,$2.11 ,$0.59 ,$1.93 ,$1.48 ,$1.77 ,$1.93 ,$1.93 ,$1.93 ,$0.78 ,$1.27 ,$0.63 ,$1.90 ,$1.58 ,$1.69 ,$1.75
Hoopeston Regional Hlth Center,8980259,diazoxide 50 mg/mL oral suspension,575620030,,259,$87.17 ,$87.17 ,$24.41 ,$79.76 ,$61.02 ,$72.96 ,$79.76 ,$79.76 ,$79.76 ,$32.12 ,$52.30 ,$26.15 ,$78.45 ,$65.38 ,$69.74 ,$72.35
Hoopeston Regional Hlth Center,8980259,estazolam 2 mg tablet,591074501,,259,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980259,probenecid 500 mg-colchicine 0.5 mg tablet,591532501,,259,$6.84 ,$6.84 ,$1.92 ,$6.26 ,$4.79 ,$5.73 ,$6.26 ,$6.26 ,$6.26 ,$2.52 ,$4.10 ,$2.05 ,$6.16 ,$5.13 ,$5.47 ,$5.68
Hoopeston Regional Hlth Center,8980259,minocycline 50 mg capsule,591569401,,259,$10.25 ,$10.25 ,$2.87 ,$9.38 ,$7.18 ,$8.58 ,$9.38 ,$9.38 ,$9.38 ,$3.78 ,$6.15 ,$3.08 ,$9.23 ,$7.69 ,$8.20 ,$8.51
Hoopeston Regional Hlth Center,8980259,promethazine 6.25 mg-codeine 10 mg/5 mL syrup,603158554,,259,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980259,amitriptyline 50 mg tablet,603221421,,259,$8.25 ,$8.25 ,$2.31 ,$7.55 ,$5.78 ,$6.91 ,$7.55 ,$7.55 ,$7.55 ,$3.04 ,$4.95 ,$2.48 ,$7.43 ,$6.19 ,$6.60 ,$6.85
Hoopeston Regional Hlth Center,8980259,promethazine 50 mg rectal suppository,713013212,,259,$133.33 ,$133.33 ,$37.33 ,$122.00 ,$93.33 ,$111.60 ,$122.00 ,$122.00 ,$122.00 ,$49.13 ,$80.00 ,$40.00 ,$120.00 ,$100.00 ,$106.66 ,$110.66
Hoopeston Regional Hlth Center,8980259,fentaNYL 12 mcg/hr transdermal patch,781724055,,259,$81.55 ,$81.55 ,$22.83 ,$74.62 ,$57.09 ,$68.26 ,$74.62 ,$74.62 ,$74.62 ,$30.05 ,$48.93 ,$24.47 ,$73.40 ,$61.16 ,$65.24 ,$67.69
Hoopeston Regional Hlth Center,8980259,trifluoperazine 1 mg tablet,832049411,,259,$6.41 ,$6.41 ,$1.79 ,$5.87 ,$4.49 ,$5.37 ,$5.87 ,$5.87 ,$5.87 ,$2.36 ,$3.85 ,$1.92 ,$5.77 ,$4.81 ,$5.13 ,$5.32
Hoopeston Regional Hlth Center,8980259,"nitroglycerin ER 2.5 mg capsule,extended release",904064360,,259,$5.56 ,$5.56 ,$1.56 ,$5.09 ,$3.89 ,$4.65 ,$5.09 ,$5.09 ,$5.09 ,$2.05 ,$3.34 ,$1.67 ,$5.00 ,$4.17 ,$4.45 ,$4.61
Hoopeston Regional Hlth Center,8980259,povidone-iodine 10 % topical ointment,904110231,,259,$20.66 ,$20.66 ,$5.78 ,$18.90 ,$14.46 ,$17.29 ,$18.90 ,$18.90 ,$18.90 ,$7.61 ,$12.40 ,$6.20 ,$18.59 ,$15.50 ,$16.53 ,$17.15
Hoopeston Regional Hlth Center,8980259,"calcium carbonate 600 mg calcium (1,500 mg) tablet",904323261,,259,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980259,guaiFENesin 200 mg tablet,904515460,,259,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980259,emollient topical gel,8327080979,,259,"$1,076.18 ","$1,076.18 ",$301.33 ,$984.70 ,$753.33 ,$900.76 ,$984.70 ,$984.70 ,$984.70 ,$396.57 ,$645.71 ,$322.85 ,$968.56 ,$807.14 ,$860.94 ,$893.23
Hoopeston Regional Hlth Center,8980259,mineral oil oral,9999029135,,259,$9.43 ,$9.43 ,$2.64 ,$8.63 ,$6.60 ,$7.89 ,$8.63 ,$8.63 ,$8.63 ,$3.47 ,$5.66 ,$2.83 ,$8.49 ,$7.07 ,$7.54 ,$7.83
Hoopeston Regional Hlth Center,8980259,famotidine 40 mg/5 mL (8 mg/mL) oral suspension,9999045055,,259,$26.80 ,$26.80 ,$7.50 ,$24.52 ,$18.76 ,$22.43 ,$24.52 ,$24.52 ,$24.52 ,$9.88 ,$16.08 ,$8.04 ,$24.12 ,$20.10 ,$21.44 ,$22.24
Hoopeston Regional Hlth Center,8980259,,9999401055,,259,$50.02 ,$50.02 ,$14.01 ,$45.77 ,$35.01 ,$41.87 ,$45.77 ,$45.77 ,$45.77 ,$18.43 ,$30.01 ,$15.01 ,$45.02 ,$37.52 ,$40.02 ,$41.52
Hoopeston Regional Hlth Center,8980259,efavirenz 600 mg-emtricitabine 200 mg-tenofovir disoprox 300 mg tablet,15584010101,,259,$427.41 ,$427.41 ,$119.67 ,$391.08 ,$299.19 ,$357.74 ,$391.08 ,$391.08 ,$391.08 ,$157.50 ,$256.45 ,$128.22 ,$384.67 ,$320.56 ,$341.93 ,$354.75
Hoopeston Regional Hlth Center,8980259,isradipine 2.5 mg capsule,16252053901,,259,$8.69 ,$8.69 ,$2.43 ,$7.95 ,$6.08 ,$7.27 ,$7.95 ,$7.95 ,$7.95 ,$3.20 ,$5.21 ,$2.61 ,$7.82 ,$6.52 ,$6.95 ,$7.21
Hoopeston Regional Hlth Center,8980259,amitriptyline 50 mg tablet,16729017301,,259,$8.25 ,$8.25 ,$2.31 ,$7.55 ,$5.78 ,$6.91 ,$7.55 ,$7.55 ,$7.55 ,$3.04 ,$4.95 ,$2.48 ,$7.43 ,$6.19 ,$6.60 ,$6.85
Hoopeston Regional Hlth Center,8980259,phenylephrine 2.5 % eye drops,17478020102,,259,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980259,sodium chloride 5 % eye drops,17478062312,,259,$89.32 ,$89.32 ,$25.01 ,$81.73 ,$62.52 ,$74.76 ,$81.73 ,$81.73 ,$81.73 ,$32.91 ,$53.59 ,$26.80 ,$80.39 ,$66.99 ,$71.46 ,$74.14
Hoopeston Regional Hlth Center,8980259,propranoloL 80 mg tablet,23155011401,,259,$6.51 ,$6.51 ,$1.82 ,$5.96 ,$4.56 ,$5.45 ,$5.96 ,$5.96 ,$5.96 ,$2.40 ,$3.91 ,$1.95 ,$5.86 ,$4.88 ,$5.21 ,$5.40
Hoopeston Regional Hlth Center,8980259,sulfacetamide-prednisolone 10 %-0.23 % (0.25 %) eye drops,24208031705,,259,$108.35 ,$108.35 ,$30.34 ,$99.14 ,$75.85 ,$90.69 ,$99.14 ,$99.14 ,$99.14 ,$39.93 ,$65.01 ,$32.51 ,$97.52 ,$81.26 ,$86.68 ,$89.93
Hoopeston Regional Hlth Center,8980259,dorzolamide 22.3 mg-timoloL 6.8 mg/mL eye drops,24208048610,,259,$335.47 ,$335.47 ,$93.93 ,$306.96 ,$234.83 ,$280.79 ,$306.96 ,$306.96 ,$306.96 ,$123.62 ,$201.28 ,$100.64 ,$301.92 ,$251.60 ,$268.38 ,$278.44
Hoopeston Regional Hlth Center,8980259,"neomycin-polymyxin-hydrocort 3.5 mg-10,000 unit/mL-1 % ear drops,susp",24208063562,,259,$490.14 ,$490.14 ,$137.24 ,$448.48 ,$343.10 ,$410.25 ,$448.48 ,$448.48 ,$448.48 ,$180.62 ,$294.08 ,$147.04 ,$441.13 ,$367.61 ,$392.11 ,$406.82
Hoopeston Regional Hlth Center,8980259,prednisoLONE sodium phosphate 1 % eye drops,24208071510,,259,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980259,sodium hypochlorite 0.25 % solution,39328006325,,259,$83.33 ,$83.33 ,$23.33 ,$76.25 ,$58.33 ,$69.75 ,$76.25 ,$76.25 ,$76.25 ,$30.71 ,$50.00 ,$25.00 ,$75.00 ,$62.50 ,$66.66 ,$69.16
Hoopeston Regional Hlth Center,8980259,trolamine salicylate-aloe vera 10 % topical cream,41167005703,,259,$61.87 ,$61.87 ,$17.32 ,$56.61 ,$43.31 ,$51.79 ,$56.61 ,$56.61 ,$56.61 ,$22.80 ,$37.12 ,$18.56 ,$55.68 ,$46.40 ,$49.50 ,$51.35
Hoopeston Regional Hlth Center,8980259,methyl salicylate 15 %-menthol 10 % topical cream,41167006003,,259,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980259,alendronate 5 mg tablet,41616063583,,259,$15.97 ,$15.97 ,$4.47 ,$14.61 ,$11.18 ,$13.37 ,$14.61 ,$14.61 ,$14.61 ,$5.88 ,$9.58 ,$4.79 ,$14.37 ,$11.98 ,$12.78 ,$13.26
Hoopeston Regional Hlth Center,8980259,alendronate 10 mg tablet,41616063688,,259,$15.96 ,$15.96 ,$4.47 ,$14.60 ,$11.17 ,$13.36 ,$14.60 ,$14.60 ,$14.60 ,$5.88 ,$9.58 ,$4.79 ,$14.36 ,$11.97 ,$12.77 ,$13.25
Hoopeston Regional Hlth Center,8980259,clotrimazole 1 % topical cream,45802043411,J3490,259,$53.44 ,$53.44 ,$14.96 ,$48.90 ,$37.41 ,$44.73 ,$48.90 ,$48.90 ,$48.90 ,$19.69 ,$32.06 ,$16.03 ,$48.10 ,$40.08 ,$42.75 ,$44.36
Hoopeston Regional Hlth Center,8980259,econazole 1 % topical cream,45802046635,,259,$160.98 ,$160.98 ,$45.07 ,$147.30 ,$112.69 ,$134.74 ,$147.30 ,$147.30 ,$147.30 ,$59.32 ,$96.59 ,$48.29 ,$144.88 ,$120.74 ,$128.78 ,$133.61
Hoopeston Regional Hlth Center,8980259,Lactobacillus rhamnosus GG 10 billion cell capsule,49100040007,,259,$1.60 ,$1.60 ,$0.45 ,$1.46 ,$1.12 ,$1.34 ,$1.46 ,$1.46 ,$1.46 ,$0.59 ,$0.96 ,$0.48 ,$1.44 ,$1.20 ,$1.28 ,$1.33
Hoopeston Regional Hlth Center,8980259,lamiVUDine 150 mg-zidovudine 300 mg tablet,49702020218,,259,$71.25 ,$71.25 ,$19.95 ,$65.19 ,$49.88 ,$59.64 ,$65.19 ,$65.19 ,$65.19 ,$26.26 ,$42.75 ,$21.38 ,$64.13 ,$53.44 ,$57.00 ,$59.14
Hoopeston Regional Hlth Center,8980259,pentosan polysulfate sodium 100 mg capsule,50458009801,,259,$48.40 ,$48.40 ,$13.55 ,$44.29 ,$33.88 ,$40.51 ,$44.29 ,$44.29 ,$44.29 ,$17.84 ,$29.04 ,$14.52 ,$43.56 ,$36.30 ,$38.72 ,$40.17
Hoopeston Regional Hlth Center,8980259,"paliperidone ER 6 mg tablet,extended release 24 hr",50458055101,,259,$59.65 ,$59.65 ,$16.70 ,$54.58 ,$41.76 ,$49.93 ,$54.58 ,$54.58 ,$54.58 ,$21.98 ,$35.79 ,$17.90 ,$53.69 ,$44.74 ,$47.72 ,$49.51
Hoopeston Regional Hlth Center,8980259,rivaroxaban 15 mg tablet,50458057810,,259,$77.10 ,$77.10 ,$21.59 ,$70.55 ,$53.97 ,$64.53 ,$70.55 ,$70.55 ,$70.55 ,$28.41 ,$46.26 ,$23.13 ,$69.39 ,$57.83 ,$61.68 ,$63.99
Hoopeston Regional Hlth Center,8980259,rivaroxaban 20 mg tablet,50458057910,,259,$77.10 ,$77.10 ,$21.59 ,$70.55 ,$53.97 ,$64.53 ,$70.55 ,$70.55 ,$70.55 ,$28.41 ,$46.26 ,$23.13 ,$69.39 ,$57.83 ,$61.68 ,$63.99
Hoopeston Regional Hlth Center,8980259,indomethacin 50 mg capsule,51079019120,,259,$5.49 ,$5.49 ,$1.54 ,$5.02 ,$3.84 ,$4.60 ,$5.02 ,$5.02 ,$5.02 ,$2.02 ,$3.29 ,$1.65 ,$4.94 ,$4.12 ,$4.39 ,$4.56
Hoopeston Regional Hlth Center,8980259,doxepin 10 mg capsule,51079043620,,259,$5.31 ,$5.31 ,$1.49 ,$4.86 ,$3.72 ,$4.44 ,$4.86 ,$4.86 ,$4.86 ,$1.96 ,$3.19 ,$1.59 ,$4.78 ,$3.98 ,$4.25 ,$4.41
Hoopeston Regional Hlth Center,8980259,dilTIAZem 90 mg tablet,51079074720,,259,$6.32 ,$6.32 ,$1.77 ,$5.78 ,$4.42 ,$5.29 ,$5.78 ,$5.78 ,$5.78 ,$2.33 ,$3.79 ,$1.90 ,$5.69 ,$4.74 ,$5.06 ,$5.25
Hoopeston Regional Hlth Center,8980259,sucralfate 1 gram tablet,51079075320,,259,$4.10 ,$4.10 ,$1.15 ,$3.75 ,$2.87 ,$3.43 ,$3.75 ,$3.75 ,$3.75 ,$1.51 ,$2.46 ,$1.23 ,$3.69 ,$3.08 ,$3.28 ,$3.40
Hoopeston Regional Hlth Center,8980259,"verapamiL ER (SR) 240 mg tablet,extended release",51079086920,,259,$14.14 ,$14.14 ,$3.96 ,$12.94 ,$9.90 ,$11.84 ,$12.94 ,$12.94 ,$12.94 ,$5.21 ,$8.48 ,$4.24 ,$12.73 ,$10.61 ,$11.31 ,$11.74
Hoopeston Regional Hlth Center,8980259,"verapamiL ER (SR) 180 mg tablet,extended release",51079089920,,259,$13.94 ,$13.94 ,$3.90 ,$12.76 ,$9.76 ,$11.67 ,$12.76 ,$12.76 ,$12.76 ,$5.14 ,$8.36 ,$4.18 ,$12.55 ,$10.46 ,$11.15 ,$11.57
Hoopeston Regional Hlth Center,8980259,clobetasoL 0.05 % topical ointment,51672125901,,259,$745.34 ,$745.34 ,$208.70 ,$681.99 ,$521.74 ,$623.85 ,$681.99 ,$681.99 ,$681.99 ,$274.66 ,$447.20 ,$223.60 ,$670.81 ,$559.01 ,$596.27 ,$618.63
Hoopeston Regional Hlth Center,8980259,fluocinonide 0.05 % topical ointment,51672126401,,259,$350.69 ,$350.69 ,$98.19 ,$320.88 ,$245.48 ,$293.53 ,$320.88 ,$320.88 ,$320.88 ,$129.23 ,$210.41 ,$105.21 ,$315.62 ,$263.02 ,$280.55 ,$291.07
Hoopeston Regional Hlth Center,8980259,ketoconazole 2 % topical cream,51672129802,,259,$992.30 ,$992.30 ,$277.84 ,$907.95 ,$694.61 ,$830.56 ,$907.95 ,$907.95 ,$907.95 ,$365.66 ,$595.38 ,$297.69 ,$893.07 ,$744.23 ,$793.84 ,$823.61
Hoopeston Regional Hlth Center,8980259,tolnaftate 1 % topical cream,51672202001,,259,$33.18 ,$33.18 ,$9.29 ,$30.36 ,$23.23 ,$27.77 ,$30.36 ,$30.36 ,$30.36 ,$12.23 ,$19.91 ,$9.95 ,$29.86 ,$24.89 ,$26.54 ,$27.54
Hoopeston Regional Hlth Center,8980259,OXcarbazepine 150 mg tablet,51991029201,,259,$9.03 ,$9.03 ,$2.53 ,$8.26 ,$6.32 ,$7.56 ,$8.26 ,$8.26 ,$8.26 ,$3.33 ,$5.42 ,$2.71 ,$8.13 ,$6.77 ,$7.22 ,$7.49
Hoopeston Regional Hlth Center,8980259,fluocinolone 0.025 % topical cream,52565002015,,259,$184.54 ,$184.54 ,$51.67 ,$168.85 ,$129.18 ,$154.46 ,$168.85 ,$168.85 ,$168.85 ,$68.00 ,$110.72 ,$55.36 ,$166.09 ,$138.41 ,$147.63 ,$153.17
Hoopeston Regional Hlth Center,8980259,naproxen 375 mg tablet,53746018901,,259,$7.29 ,$7.29 ,$2.04 ,$6.67 ,$5.10 ,$6.10 ,$6.67 ,$6.67 ,$6.67 ,$2.69 ,$4.37 ,$2.19 ,$6.56 ,$5.47 ,$5.83 ,$6.05
Hoopeston Regional Hlth Center,8980259,"carBAMazepine ER 300 mg capsule,extended release mphase12hr",54092017312,,259,$12.24 ,$12.24 ,$3.43 ,$11.20 ,$8.57 ,$10.24 ,$11.20 ,$11.20 ,$11.20 ,$4.51 ,$7.34 ,$3.67 ,$11.02 ,$9.18 ,$9.79 ,$10.16
Hoopeston Regional Hlth Center,8980259,pseudoephedrine 15 mg/5 mL oral liquid,54838010440,,259,$9.32 ,$9.32 ,$2.61 ,$8.53 ,$6.52 ,$7.80 ,$8.53 ,$8.53 ,$8.53 ,$3.43 ,$5.59 ,$2.80 ,$8.39 ,$6.99 ,$7.46 ,$7.74
Hoopeston Regional Hlth Center,8980259,ofloxacin 400 mg tablet,55111016201,,259,$29.16 ,$29.16 ,$8.16 ,$26.68 ,$20.41 ,$24.41 ,$26.68 ,$26.68 ,$26.68 ,$10.75 ,$17.50 ,$8.75 ,$26.24 ,$21.87 ,$23.33 ,$24.20
Hoopeston Regional Hlth Center,8980259,metFORMIN 850 mg tablet,57664043551,,259,$7.91 ,$7.91 ,$2.21 ,$7.24 ,$5.54 ,$6.62 ,$7.24 ,$7.24 ,$7.24 ,$2.91 ,$4.75 ,$2.37 ,$7.12 ,$5.93 ,$6.33 ,$6.57
Hoopeston Regional Hlth Center,8980259,"aspirin 325 mg tablet,delayed release",57896092110,,259,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980259,clindamycin 75 mg/5 mL oral solution,59762001601,,259,$367.83 ,$367.83 ,$102.99 ,$336.56 ,$257.48 ,$307.87 ,$336.56 ,$336.56 ,$336.56 ,$135.55 ,$220.70 ,$110.35 ,$331.05 ,$275.87 ,$294.26 ,$305.30
Hoopeston Regional Hlth Center,8980259,triamcinolone acetonide 0.1 % lotion,60432056160,,259,$218.65 ,$218.65 ,$61.22 ,$200.06 ,$153.06 ,$183.01 ,$200.06 ,$200.06 ,$200.06 ,$80.57 ,$131.19 ,$65.60 ,$196.79 ,$163.99 ,$174.92 ,$181.48
Hoopeston Regional Hlth Center,8980259,"alfuzosin ER 10 mg tablet,extended release 24 hr",60505285001,,259,$21.99 ,$21.99 ,$6.16 ,$20.12 ,$15.39 ,$18.41 ,$20.12 ,$20.12 ,$20.12 ,$8.10 ,$13.19 ,$6.60 ,$19.79 ,$16.49 ,$17.59 ,$18.25
Hoopeston Regional Hlth Center,8980259,ezetimibe 10 mg tablet,60505294503,,259,$44.13 ,$44.13 ,$12.36 ,$40.38 ,$30.89 ,$36.94 ,$40.38 ,$40.38 ,$40.38 ,$16.26 ,$26.48 ,$13.24 ,$39.72 ,$33.10 ,$35.30 ,$36.63
Hoopeston Regional Hlth Center,8980259,fentaNYL 25 mcg/hr transdermal patch,60505700602,,259,$84.92 ,$84.92 ,$23.78 ,$77.70 ,$59.44 ,$71.08 ,$77.70 ,$77.70 ,$77.70 ,$31.29 ,$50.95 ,$25.48 ,$76.43 ,$63.69 ,$67.94 ,$70.48
Hoopeston Regional Hlth Center,8980259,rifabutin 150 mg capsule,60687019825,,259,$88.65 ,$88.65 ,$24.82 ,$81.11 ,$62.06 ,$74.20 ,$81.11 ,$81.11 ,$81.11 ,$32.67 ,$53.19 ,$26.60 ,$79.79 ,$66.49 ,$70.92 ,$73.58
Hoopeston Regional Hlth Center,8980259,timoloL maleate 0.25 % eye gel forming solution,61314022405,,259,$944.82 ,$944.82 ,$264.55 ,$864.51 ,$661.37 ,$790.81 ,$864.51 ,$864.51 ,$864.51 ,$348.17 ,$566.89 ,$283.45 ,$850.34 ,$708.62 ,$755.86 ,$784.20
Hoopeston Regional Hlth Center,8980259,timoloL maleate 0.5 % eye gel forming solution,61314022505,,259,"$1,033.45 ","$1,033.45 ",$289.37 ,$945.61 ,$723.42 ,$865.00 ,$945.61 ,$945.61 ,$945.61 ,$380.83 ,$620.07 ,$310.04 ,$930.11 ,$775.09 ,$826.76 ,$857.76
Hoopeston Regional Hlth Center,8980259,"neomycin 3.5 mg-polymyxin 10,000 unit-hydrocort 10 mg/mL eye drop,susp",61314064175,,259,$814.34 ,$814.34 ,$228.02 ,$745.12 ,$570.04 ,$681.60 ,$745.12 ,$745.12 ,$745.12 ,$300.08 ,$488.60 ,$244.30 ,$732.91 ,$610.76 ,$651.47 ,$675.90
Hoopeston Regional Hlth Center,8980259,ramipriL 1.25 mg capsule,61570011001,,259,$29.48 ,$29.48 ,$8.25 ,$26.97 ,$20.64 ,$24.67 ,$26.97 ,$26.97 ,$26.97 ,$10.86 ,$17.69 ,$8.84 ,$26.53 ,$22.11 ,$23.58 ,$24.47
Hoopeston Regional Hlth Center,8980259,"oxybutynin chloride ER 5 mg tablet,extended release 24 hr",62175027037,,259,$16.65 ,$16.65 ,$4.66 ,$15.23 ,$11.66 ,$13.94 ,$15.23 ,$15.23 ,$15.23 ,$6.14 ,$9.99 ,$5.00 ,$14.99 ,$12.49 ,$13.32 ,$13.82
Hoopeston Regional Hlth Center,8980259,"divalproex 250 mg tablet,delayed release",62756079788,,259,$10.45 ,$10.45 ,$2.93 ,$9.56 ,$7.32 ,$8.75 ,$9.56 ,$9.56 ,$9.56 ,$3.85 ,$6.27 ,$3.14 ,$9.41 ,$7.84 ,$8.36 ,$8.67
Hoopeston Regional Hlth Center,8980259,"divalproex 500 mg tablet,delayed release",62756079813,,259,$17.31 ,$17.31 ,$4.85 ,$15.84 ,$12.12 ,$14.49 ,$15.84 ,$15.84 ,$15.84 ,$6.38 ,$10.39 ,$5.19 ,$15.58 ,$12.98 ,$13.85 ,$14.37
Hoopeston Regional Hlth Center,8980259,"lansoprazole 30 mg delayed release,disintegrating tablet",64764054411,,259,$66.26 ,$66.26 ,$18.55 ,$60.63 ,$46.38 ,$55.46 ,$60.63 ,$60.63 ,$60.63 ,$24.42 ,$39.76 ,$19.88 ,$59.63 ,$49.70 ,$53.01 ,$55.00
Hoopeston Regional Hlth Center,8980259,"lansoprazole 30 mg delayed release,disintegrating tablet",64764054430,,259,$66.26 ,$66.26 ,$18.55 ,$60.63 ,$46.38 ,$55.46 ,$60.63 ,$60.63 ,$60.63 ,$24.42 ,$39.76 ,$19.88 ,$59.63 ,$49.70 ,$53.01 ,$55.00
Hoopeston Regional Hlth Center,8980259,ZOLMitriptan 2.5 mg tablet,64896067151,,259,$551.48 ,$551.48 ,$154.41 ,$504.60 ,$386.04 ,$461.59 ,$504.60 ,$504.60 ,$504.60 ,$203.22 ,$330.89 ,$165.44 ,$496.33 ,$413.61 ,$441.18 ,$457.73
Hoopeston Regional Hlth Center,8980259,ZOLMitriptan 5 mg tablet,64896067250,,259,$551.47 ,$551.47 ,$154.41 ,$504.60 ,$386.03 ,$461.58 ,$504.60 ,$504.60 ,$504.60 ,$203.22 ,$330.88 ,$165.44 ,$496.32 ,$413.60 ,$441.18 ,$457.72
Hoopeston Regional Hlth Center,8980259,olmesartan 20 mg-hydrochlorothiazide 12.5 mg tablet,65597010530,,259,$41.96 ,$41.96 ,$11.75 ,$38.39 ,$29.37 ,$35.12 ,$38.39 ,$38.39 ,$38.39 ,$15.46 ,$25.18 ,$12.59 ,$37.76 ,$31.47 ,$33.57 ,$34.83
Hoopeston Regional Hlth Center,8980259,olmesartan 40 mg-hydrochlorothiazide 25 mg tablet,65597010730,,259,$55.15 ,$55.15 ,$15.44 ,$50.46 ,$38.61 ,$46.16 ,$50.46 ,$50.46 ,$50.46 ,$20.32 ,$33.09 ,$16.55 ,$49.64 ,$41.36 ,$44.12 ,$45.77
Hoopeston Regional Hlth Center,8980259,alendronate 70 mg tablet,65862032904,,259,$79.86 ,$79.86 ,$22.36 ,$73.07 ,$55.90 ,$66.84 ,$73.07 ,$73.07 ,$73.07 ,$29.43 ,$47.92 ,$23.96 ,$71.87 ,$59.90 ,$63.89 ,$66.28
Hoopeston Regional Hlth Center,8980259,nitazoxanide 100 mg/5 mL oral suspension,67546021221,,259,"$2,939.99 ","$2,939.99 ",$823.20 ,"$2,690.09 ","$2,057.99 ","$2,460.77 ","$2,690.09 ","$2,690.09 ","$2,690.09 ","$1,083.39 ","$1,763.99 ",$882.00 ,"$2,645.99 ","$2,204.99 ","$2,351.99 ","$2,440.19 "
Hoopeston Regional Hlth Center,8980259,telmisartan 80 mg tablet,67877048484,,259,$27.68 ,$27.68 ,$7.75 ,$25.33 ,$19.38 ,$23.17 ,$25.33 ,$25.33 ,$25.33 ,$10.20 ,$16.61 ,$8.30 ,$24.91 ,$20.76 ,$22.14 ,$22.97
Hoopeston Regional Hlth Center,8980259,topiramate 100 mg tablet,68084034401,,259,$29.85 ,$29.85 ,$8.36 ,$27.31 ,$20.90 ,$24.98 ,$27.31 ,$27.31 ,$27.31 ,$11.00 ,$17.91 ,$8.96 ,$26.87 ,$22.39 ,$23.88 ,$24.78
Hoopeston Regional Hlth Center,8980259,cefproziL 250 mg/5 mL oral suspension,68180040203,,259,$29.05 ,$29.05 ,$8.13 ,$26.58 ,$20.34 ,$24.31 ,$26.58 ,$26.58 ,$26.58 ,$10.70 ,$17.43 ,$8.72 ,$26.15 ,$21.79 ,$23.24 ,$24.11
Hoopeston Regional Hlth Center,8980259,trandolapriL 2 mg tablet,68180056701,,259,$8.10 ,$8.10 ,$2.27 ,$7.41 ,$5.67 ,$6.78 ,$7.41 ,$7.41 ,$7.41 ,$2.98 ,$4.86 ,$2.43 ,$7.29 ,$6.08 ,$6.48 ,$6.72
Hoopeston Regional Hlth Center,8980259,OXcarbazepine 300 mg tablet,68462013801,,259,$14.49 ,$14.49 ,$4.06 ,$13.26 ,$10.14 ,$12.13 ,$13.26 ,$13.26 ,$13.26 ,$5.34 ,$8.69 ,$4.35 ,$13.04 ,$10.87 ,$11.59 ,$12.03
Hoopeston Regional Hlth Center,8980259,rasagiline 1 mg tablet,68546022956,,259,$135.68 ,$135.68 ,$37.99 ,$124.15 ,$94.98 ,$113.56 ,$124.15 ,$124.15 ,$124.15 ,$50.00 ,$81.41 ,$40.70 ,$122.11 ,$101.76 ,$108.54 ,$112.61
Hoopeston Regional Hlth Center,8980259,alendronate 35 mg tablet,69097022316,,259,$79.86 ,$79.86 ,$22.36 ,$73.07 ,$55.90 ,$66.84 ,$73.07 ,$73.07 ,$73.07 ,$29.43 ,$47.92 ,$23.96 ,$71.87 ,$59.90 ,$63.89 ,$66.28
Hoopeston Regional Hlth Center,8980259,escitalopram 10 mg tablet,69097084805,,259,$26.49 ,$26.49 ,$7.42 ,$24.24 ,$18.54 ,$22.17 ,$24.24 ,$24.24 ,$24.24 ,$9.76 ,$15.89 ,$7.95 ,$23.84 ,$19.87 ,$21.19 ,$21.99
Hoopeston Regional Hlth Center,9026360,IV HYDRATION INITIAL FIRST HOUR,,96360,260,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9026361,IV HYDRATION EACH ADD'L HOUR,,96361,260,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9026365,IV INFUSION INITIAL FIRST HOUR,,96365,260,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9026366,IV INFUSION EA ADD'L HOUR,,96366,260,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9496365,IV INF THER/DIAG; INITIAL UP TO 1 HOUR,,96365,260,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9496366,IV INF THER/DIAG; EACH ADDED HOUR,,96366,260,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9496367,IV INF THER/DIAG; ADD SEQUENTIAL INF NEW DRUG/SUBSTANCE,,96367,260,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9496368,IV INF THER/DIAG; CONCURRENT INF,,96368,260,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9496374,IVP THER/DIAG; INITIAL DRUG/SUBSTANCE,,96374,260,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9496375,IVP THER/DIAG; NEW DRUG/SUBSTANCE,,96375,260,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9496376,IVP THER/DIAG; ADD SEQUENTIAL SAME DRUG/SUBSTANCE,,96376,260,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9496360,"IV HYDRATION; INITIAL, 31 MINUTES TO 1 HOUR",,96360,260,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9496361,IV HYDRATION; EACH ADDED HOUR,,96361,260,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9496372,INJ IM OR SUBQ,,96372,260,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9096367,INFUSION SEQUENTIAL,,96367,260,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9096368,CONCURRENT INFUSION,,96368,260,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9096372,IM OR SUBQ INJ ADMIN,,96372,260,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9096374,IV PUSH ADMINISTRATION,,96374,260,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9096375,IV PUSH ADDITIONAL NEW DRUG,,96375,260,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9096376,IV PUSH SAME DRUG >30 MIN,,96376,260,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,96360,"IV INFUSION, HYDRATION, 31-60 MIN",,96360,260,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,96361,"IV INFUSION, HYDRATION, EA ADD HOUR",,96361,260,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,96365,"IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,1ST HOUR",,96365,260,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,96366,"IV INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,EA ADD HOUR",,96366,260,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9800004,CO2 SAMPLING LINE PEDIATRIC,,,270,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9800005,IMPEDANCE THRESHOLD DEVICE,,,270,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9800006,NOSE BLEED TRAY,,,270,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9800007,SUTURE,,,270,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9800008,TOPICAL SKIN ADHESIVE,,,270,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9800009,INFANT SPO2 DISPOSABLE SENSOR,,,270,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9800010,NASAL FOAM,,,270,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9800011,NASAL FOAM,,,270,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9800012,NASAL FOAM,,,270,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9800013,NASAL FOAM,,,270,$97.00 ,$97.00 ,$27.16 ,$88.76 ,$67.90 ,$81.19 ,$88.76 ,$88.76 ,$88.76 ,$35.74 ,$58.20 ,$29.10 ,$87.30 ,$72.75 ,$77.60 ,$80.51
Hoopeston Regional Hlth Center,9800014,NASAL FOAM,,,270,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,9800015,NASAL FOAM,,,270,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9800016,EYE TRAY,,,270,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9800017,ADULT I.O. NEEDLE 15G 25MM,,,270,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,9800018,CHILD I.O. NEEDLE 15G 15MM,,,270,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9800019,INFANT I.O. PATCH,,,270,$91.00 ,$91.00 ,$25.48 ,$83.27 ,$63.70 ,$76.17 ,$83.27 ,$83.27 ,$83.27 ,$33.53 ,$54.60 ,$27.30 ,$81.90 ,$68.25 ,$72.80 ,$75.53
Hoopeston Regional Hlth Center,9800020,CHILD I.O. PATCH,,,270,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9800021,EAR TRAY,,,270,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9800022,NASAL TRAY,,,270,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9800023,MAGNIFIED LIGHTED EARCURETTE,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9800024,TEMPORARY FILLING MATERIAL,,,270,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9800025,SUMP DRAIN,,,270,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9800026,HEMOSTASIS VALVE,,,270,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9800027,RHINO EXTRACTOR,,,270,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9800028,INFANT TRANSWARMER,,,270,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9800029,NASAL ASPIRATOR,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800030,NASAL FOAM,,,270,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9800031,SALINE FLUSH SYRINGE 3CC,,,270,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9800032,SALINE FLUSH SYRINGE 12CC,,,270,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9800033,LARYNGEAL MASK AIRWAY (LMA),,,270,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9800062,VAG EXAM,,,270,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9800077,LAVAGE TRAY,,,270,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9650008,OXYGEN PER DAY,,,270,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9650009,SODIUM CHLORIDE SOL,,,270,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9650010,SUCTION N' CUP KIT,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9650011,OXYGEN MASK,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9650012,BAG VALVE MASK,,,270,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,9650013,OXYGEN EXTENSION TUBING,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9650015,ARTERIAL BLOOD GAS W/ANALYSIS,,,270,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,9650016,NASALPHARYNGEAL TUBE,,,270,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9650017,PEDIATRIC NASAL CANNULA,,,270,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9650018,TRACH MASK,,,270,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9650019,PED OXYGEN MASK,,,270,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9650020,INFANT OXYGEN MASK,,,270,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9650021,PED AERO MASK,,,270,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9650022,NORMAL SALINE 3ML FOR INHALER,,,270,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9650023,MASK NON REBREATHER,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9650024,NASAL CANNULA,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9650025,BIPAP MASK ALL SIZES,,,270,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9650026,BIPAP BACTERIA FILTER,,,270,$13.00 ,$13.00 ,$3.64 ,$11.90 ,$9.10 ,$10.88 ,$11.90 ,$11.90 ,$11.90 ,$4.79 ,$7.80 ,$3.90 ,$11.70 ,$9.75 ,$10.40 ,$10.79
Hoopeston Regional Hlth Center,9650027,BIPAP CIRCUIT,,,270,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9650028,HUMIDIFIER BOTTLE,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9650029,AEROSOL CIRCUIT,,,270,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9650030,AEROSOL MASK,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9650031,NEBULIZER TX SUPPLIES,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9650032,INCENTIVE DEVICE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9650033,VENTILATOR CIRCUIT,,,270,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9650034,AIR ENTRAINMENT MASK,,,270,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9650035,ORAL AIRWAY,,,270,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9650036,OXYGEN INCREMEN PER HR,,,270,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9650037,SPEAKING VALVE,,,270,$400.00 ,$400.00 ,$112.00 ,$366.00 ,$280.00 ,$334.80 ,$366.00 ,$366.00 ,$366.00 ,$147.40 ,$240.00 ,$120.00 ,$360.00 ,$300.00 ,$320.00 ,$332.00
Hoopeston Regional Hlth Center,9650038,PEAK FLOW METER-STANDARD,,,270,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9650039,RACEMIC EPINEPHRINE,,,270,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9650040,E TANK,,,270,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9650043,OXYGEN SENSOR-DISP,,,270,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9650044,CODE BOX,,,270,$325.00 ,$325.00 ,$91.00 ,$297.38 ,$227.50 ,$272.03 ,$297.38 ,$297.38 ,$297.38 ,$119.76 ,$195.00 ,$97.50 ,$292.50 ,$243.75 ,$260.00 ,$269.75
Hoopeston Regional Hlth Center,9670200,MISCELLANEOUS SUPPLIES,,,270,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9670045,CPM DAILY RENTAL,,,270,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9670011,ADJ TORSION STYLE MECHANISM,,,270,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9670014,AFO ORTHOSIS FLOOR-REACT,,,270,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9670019,AFO/SMO,,,270,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9670021,"ANKLE FOOT ORTHOSIS""HINGED""",,,270,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9670065,ELBOW HINGED SPLINT (2 HINGES),,,270,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9670132,PEDIATRIC ELBOW,,,270,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9670139,WOUND DEBRIDEMENT SYSTEM,,,270,$215.00 ,$215.00 ,$60.20 ,$196.73 ,$150.50 ,$179.96 ,$196.73 ,$196.73 ,$196.73 ,$79.23 ,$129.00 ,$64.50 ,$193.50 ,$161.25 ,$172.00 ,$178.45
Hoopeston Regional Hlth Center,9670160,SI BELT REGULAR/LARGE (BACK MA,,,270,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9670161,SI BELTS SAUNDERS,,,270,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9670162,SI LOC (LARGE/XLARGE),,,270,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9670163,SI LOC (SMALL/MED.),,,270,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9670169,STELLAR SI BELT,,,270,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9336525,PALL FILTER,,,270,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9730001,BACK BRACE,,,270,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9700005,OT ELECTRODES,,,270,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9730003,OT THERABAND,,,270,$13.00 ,$13.00 ,$3.64 ,$11.90 ,$9.10 ,$10.88 ,$11.90 ,$11.90 ,$11.90 ,$4.79 ,$7.80 ,$3.90 ,$11.70 ,$9.75 ,$10.40 ,$10.79
Hoopeston Regional Hlth Center,9150036,OXYGEN INCREMEN PER HR,,,270,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9800100,CENTRAL VENOUS CATH,,,270,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9800101,FILTER NEEDLES,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800102,INFUSION SET,,,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9800103,CHILD I.O. PATCH,,,270,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,9800104,GAUZE 2',,,270,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9800105,BUETROL,,,270,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9800106,AMMONIA AMPULE,,,270,$13.00 ,$13.00 ,$3.64 ,$11.90 ,$9.10 ,$10.88 ,$11.90 ,$11.90 ,$11.90 ,$4.79 ,$7.80 ,$3.90 ,$11.70 ,$9.75 ,$10.40 ,$10.79
Hoopeston Regional Hlth Center,9800107,SODIUM CHLORIDE,,,270,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9800109,VAG SPECULUM SMALL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800110,"MASK, TRACH",,,270,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9800111,PALL BLOOD FILTERS,,,270,$25.00 ,$25.00 ,$7.00 ,$22.88 ,$17.50 ,$20.93 ,$22.88 ,$22.88 ,$22.88 ,$9.21 ,$15.00 ,$7.50 ,$22.50 ,$18.75 ,$20.00 ,$20.75
Hoopeston Regional Hlth Center,9800112,SODIUM CHLORIDE,,,270,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9800113,HUBER NEEDLE,,,270,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9800114,LEG URINE DRAIN BAG,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800115,ABD COMBINE DRESSING,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800116,"BANDAGE 2""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800117,"BANDAGE 3""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800118,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800119,"BANDAGE 4""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800120,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800121,"BANDAGE 6""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800122,"BANDAGE 2""",,,270,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9800124,"BANDAGE 3""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800125,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800126,POTASSIUM CHLORIDE RIDER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800127,POTASSIUM CHLORIDE RIDER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800128,MINERAL OIL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800129,SCALPEL BLADE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800130,SLING,,,270,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9800131,LACTATED RINGERS,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800132,ELECTRODES,,,270,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9800133,EYE PAD,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9800134,MINERAL OIL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800135,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800136,"DRESSING STRIP 1/4""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800137,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800138,"DRESSING STRIP 1/2""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800139,IRRIGATION NACL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800140,"GAUZE 1/4""",,,270,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9800141,"GAUZE 1""",,,270,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9800142,IRRIGATION NACL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800143,COCK-UP SPLINT,,,270,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9800144,"DRESSING STRIP 1""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800145,FOLEY TRAY,,,270,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9800146,FEEDING TUBE 8FR.,,,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9800147,STRAIGHT CATH TRAY URETERAL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800148,DRAINBAG,,,270,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9800149,"BANDAGE 6""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800150,IRRIGATION TRAY,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800151,YANKUER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800152,STERILE 2 X2 GAUZE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800153,LACERATION TRAY,,,270,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9800154,ABSOBENT COTTON PAD 3 X 4,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800155,LUMBAR PUNCTURE TRAY,,,270,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9800156,HEAVY DRAIN PACKS,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9800157,FINGER SPLINT,,,270,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9800158,PCA PUMP TUBING,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800159,T-U-R SET,,,270,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9800160,SECONDARY ADMINISTRATION SET,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800161,URINE METER BAG 4000ML,,,270,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9800162,GAUZE 1 X 36,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800163,GAUZE 6X36,,,270,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9800164,DEXTROSE,,,270,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9800165,GAUZE 3 X 9,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800166,TRANSPARENT FILM DRESSING SMALL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800167,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800168,CLEANSING ENEMA SET,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800169,SODIUM CHLORIDE,,,270,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9800170,SODIUM CHLORIDE,,,270,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9800171,IRRIGATION WATER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800172,LAP SPONGE,,,270,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9800173,CATHETER SECURE,,,270,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9800174,FEMALE URINE COLLECTION KIT,,,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9800175,SODIUM CHLORIDE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800176,SUTURE REMOVAL KIT,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800177,MALE ADAPTER LONG LOCKING,,,270,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9800178,STERILE STRIPS,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9800179,SMALL SUCTION CANNISTER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800180,Y-TYPE BLOOD SET,,,270,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9800181,STAPLE REMOVER KIT,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800182,BABY BOTTLE,,,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9800183,ELECTRODES- PEDS,,,270,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9800184,POLYMERIC ADSOBENT,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800185,INFUSION SET,,,270,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9800186,CLAVE CONNECTOR,,,270,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9800187,TOPICAL SKIN ADHESIVE,,,270,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9800188,NITROGLYCERIN SET,,,270,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9800189,"DRESSING STRIP 2""",,,270,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9800190,STERILE 4 X4 TOPPERS,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800191,TRANSPARENT FILM DRESSING LARGE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800192,MONTGOMERY STRAP,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800193,CATH PLUG,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800194,GAUZE TRAY,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800195,SYRINGE 20CC,,,270,$6.00 ,$6.00 ,$1.68 ,$5.49 ,$4.20 ,$5.02 ,$5.49 ,$5.49 ,$5.49 ,$2.21 ,$3.60 ,$1.80 ,$5.40 ,$4.50 ,$4.80 ,$4.98
Hoopeston Regional Hlth Center,9800196,SYRINGE 60CC,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9800197,SYRINGE 2OZ CATH TIP,,,270,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9800198,COBAN,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800199,NASAL CATHETER,,,270,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9800200,EAR WICK,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800201,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800202,POTASSIUM CHLORIDE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000100,TEXAS CATH,,,270,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9000101,SUCTION CATH KIT,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000102,SIMPLE MASK,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000103,EXTENSION TUBING,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000104,KNEE WRAP,,,270,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9000105,PISTON IRRIGATION TRAY,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000106,TRANSPARENT FILM DRESSING 20 X 30,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000107,4X8 FOAM DRESSING,,,270,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9000108,FILTER NEEDLES,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000109,INFUSION SET,,,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9000110,SODIUM CHLORIDE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000111,BUETROL,,,270,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9000112,SODIUM CHLORIDE,,,270,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9000113,PALL BLOOD FILTERS,,,270,$25.00 ,$25.00 ,$7.00 ,$22.88 ,$17.50 ,$20.93 ,$22.88 ,$22.88 ,$22.88 ,$9.21 ,$15.00 ,$7.50 ,$22.50 ,$18.75 ,$20.00 ,$20.75
Hoopeston Regional Hlth Center,9000114,LEG URINE DRAIN BAG,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000115,ABD COMBINE DRESSING,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000116,MASK NON-REBREATHER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000117,NASAL CANNULAS,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000118,ABDOMINAL BINDER LG,,,270,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9000119,"BANDAGE 3""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000120,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000121,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000122,"BANDAGE 3""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000123,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000124,POTASSIUM CHLORIDE RIDER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000125,POTASSIUM CHLORIDE RIDER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000126,SODIUM CHLORIDE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000127,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000128,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000129,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000130,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000131,BUBBLE BOTTLE 340ML,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000132,MINERAL OIL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000133,LACTATED RINGERS,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000134,BARRIER CREAM,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000135,MINERAL OIL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000136,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000137,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000138,IRRIGATION NACL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000139,STOMACH TUBE SALEM 16FR.-18FR.,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000140,NEBULIZERS,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000141,FOLEY TRAY,,,270,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9000142,FEEDING TUBE 8FR.,,,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9000143,STRAIGHT CATH TRAY,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000144,DRAINBAG 2000ML ASP PORT,,,270,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9000145,URINE DRAIN BAG 4000ML,,,270,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9000146,"BANDAGE 6""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000147,IRRIGATION TRAY,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000148,YANKUER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000149,STERILE 2 X2 GAUZE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000150,ABSOBENT COTTON PAD 3 X 4,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000151,HEAVY DRAIN PACKS,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9000152,PCA PUMP TUBING,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000153,SECONDARY ADMINISTRATION SET,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000154,GAUZE 3 X 9,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000155,TRANSPARENT FILM DRESSING SMALL,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000156,FOLEY CATH 18FR 3-WAY,,,270,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9000157,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000158,CLEANSING ENEMA SET,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000159,SODIUM CHLORIDE,,,270,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9000160,SODIUM CHLORIDE,,,270,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9000161,IRRIGATION WATER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000162,HOSE THIGH LG,,,270,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9000163,CATHETER SECURE,,,270,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9000165,SODIUM CHLORIDE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000166,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000167,DEXTROSE,,,270,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9000168,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000169,SUTURE REMOVAL KIT,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000170,SUSPENDORY SUPPORT XLG,,,270,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9000171,"STERILE STRIPS 1/2""",,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9000172,SUCTION CANNISTER,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000173,Y-TYPE BLOOD SET,,,270,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9000174,STAPLE REMOVER KIT,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000175,INFUSION SET,,,270,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9000176,NITROGLYCERIN SET,,,270,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9000177,STERILE 4 X4 TOPPERS,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000178,TRANSPARENT FILM DRESSING LARGE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000179,TPN EXTENSION SET,,,270,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9000180,SYRINGE 20CC,,,270,$6.00 ,$6.00 ,$1.68 ,$5.49 ,$4.20 ,$5.02 ,$5.49 ,$5.49 ,$5.49 ,$2.21 ,$3.60 ,$1.80 ,$5.40 ,$4.50 ,$4.80 ,$4.98
Hoopeston Regional Hlth Center,9000181,SYRINGE 60CC,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9000182,SYRINGE 2OZ CATH TIP,,,270,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9000183,COMPRESSION DRESSING,,,270,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9000184,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000185,POTASSIUM CHLORIDE,,,270,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9000186,DEXTROSE,,,270,$13.00 ,$13.00 ,$3.64 ,$11.90 ,$9.10 ,$10.88 ,$11.90 ,$11.90 ,$11.90 ,$4.79 ,$7.80 ,$3.90 ,$11.70 ,$9.75 ,$10.40 ,$10.79
Hoopeston Regional Hlth Center,9000187,POTASSIUM CHLORIDE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000188,COMPRESSION SLEEVE,,,270,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9000189,DRESSING 4X4,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9800203,DRESSING 3X8,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800204,SKIN ADHESIVE,,,270,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9800205,SUCTION TUBING,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800206,SWABSTICKS,,,270,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9800207,SODIUM CHLORIDE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800208,AIR CAST,,,270,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9800209,GASTRIC LABAGE KIT,,,270,$93.00 ,$93.00 ,$26.04 ,$85.10 ,$65.10 ,$77.84 ,$85.10 ,$85.10 ,$85.10 ,$34.27 ,$55.80 ,$27.90 ,$83.70 ,$69.75 ,$74.40 ,$77.19
Hoopeston Regional Hlth Center,9800210,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800211,PENROSE DRAINS,,,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9800212,LEVIN TUBE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800213,IRRIGATION WATER,,,270,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9800214,ENTRI-FLEX,,,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9800215,FEEDING TUBE 5FR.,,,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9800216,EWALD TUBE,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9800217,LACTATE RINGERS,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800218,INFUSION SET,,,270,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9800219,FOLEY CATH - ALL SIZES,,,270,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9800220,C-COLLARS - ALL TYPES,,,270,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9800221,NOSE BLEED TRAY,,,270,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9800222,SUTURE PACKET - ALL TYPES,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800223,TRACH - ALL SIZES,,,270,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9800224,INFANT MATRESS WARMER,,,270,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9800225,BIPAP CIRCUIT,,,270,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9800226,BIPAP MASK - ALL SIZES,,,270,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9800227,VENTILATOR CIRCUIT,,,270,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9800228,BIPAP BACTERIA FILTER,,,270,$13.00 ,$13.00 ,$3.64 ,$11.90 ,$9.10 ,$10.88 ,$11.90 ,$11.90 ,$11.90 ,$4.79 ,$7.80 ,$3.90 ,$11.70 ,$9.75 ,$10.40 ,$10.79
Hoopeston Regional Hlth Center,9800229,CO2 SAMPLING LINE ADULT,,,270,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9800230,CO2 SAMPLING LINE PEDIATRIC,,,270,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9800231,KNEE IMMOBILIZERS- ALL TYPES AND SIZES,,,270,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,9800232,SHOULDER IMMOBILIZERS- ALL TYPES AND SIZES,,,270,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9800233,REHAB SHOE - ALL TYPES,,,270,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9800234,COLLES SPLINT,,,270,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9800235,ABSORBABLE HEMOSTAT WRAP,,,270,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9800236,CRUTCHES - ALL TYPES AND SIZES,,,270,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9800237,WALKERS,,,270,$215.00 ,$215.00 ,$60.20 ,$196.73 ,$150.50 ,$179.96 ,$196.73 ,$196.73 ,$196.73 ,$79.23 ,$129.00 ,$64.50 ,$193.50 ,$161.25 ,$172.00 ,$178.45
Hoopeston Regional Hlth Center,9800240,"BANDAGE 2""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000190,INCENTIVE DEVICE,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9000199,"BANDAGE 2""",,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9000200,FOLEY 5CC CATH,,,270,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9000201,DEXTROSE,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9650047,DISP INNER CANNULA,,,270,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9650048,TRACH AND CHANGE,,,270,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9650049,TRACH CARE KIT,,,270,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9800241,NASAL CANNULA,,,270,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9000202,DRESSING 5X5,,,270,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9800238,TWIN SITE CLAVE EXTENSION SET,,,270,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800245,EYE CAP,,,270,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9800247,KIT DRESSING LONG / SHORT,,,270,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9800248,WALKING BOOT - ALL SIZES,,,270,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9800249,MALLET SPLINT (FINGERTIP),,,270,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9800250,BAG VALVE MASK,,,270,$46.16 ,$46.16 ,$12.92 ,$42.24 ,$32.31 ,$38.64 ,$42.24 ,$42.24 ,$42.24 ,$17.01 ,$27.70 ,$13.85 ,$41.54 ,$34.62 ,$36.93 ,$38.31
Hoopeston Regional Hlth Center,9800251,BAG VALVE MASK PEDS,,,270,$31.56 ,$31.56 ,$8.84 ,$28.88 ,$22.09 ,$26.42 ,$28.88 ,$28.88 ,$28.88 ,$11.63 ,$18.94 ,$9.47 ,$28.40 ,$23.67 ,$25.25 ,$26.19
Hoopeston Regional Hlth Center,9800252,DRESSING 4 X 5,,,270,$12.64 ,$12.64 ,$3.54 ,$11.57 ,$8.85 ,$10.58 ,$11.57 ,$11.57 ,$11.57 ,$4.66 ,$7.58 ,$3.79 ,$11.38 ,$9.48 ,$10.11 ,$10.49
Hoopeston Regional Hlth Center,9800253,NEEDLE GRIPPER 19G X.72IN,,,270,$14.88 ,$14.88 ,$4.17 ,$13.62 ,$10.42 ,$12.45 ,$13.62 ,$13.62 ,$13.62 ,$5.48 ,$8.93 ,$4.46 ,$13.39 ,$11.16 ,$11.90 ,$12.35
Hoopeston Regional Hlth Center,9800254,NEEDLE GRIPPER 19G X.1IN,,,270,$14.88 ,$14.88 ,$4.17 ,$13.62 ,$10.42 ,$12.45 ,$13.62 ,$13.62 ,$13.62 ,$5.48 ,$8.93 ,$4.46 ,$13.39 ,$11.16 ,$11.90 ,$12.35
Hoopeston Regional Hlth Center,9800255,NEEDLE GRIPPER 22G X.72IN,,,270,$14.88 ,$14.88 ,$4.17 ,$13.62 ,$10.42 ,$12.45 ,$13.62 ,$13.62 ,$13.62 ,$5.48 ,$8.93 ,$4.46 ,$13.39 ,$11.16 ,$11.90 ,$12.35
Hoopeston Regional Hlth Center,9800256,MAXI A,,,270,$23.72 ,$23.72 ,$6.64 ,$21.70 ,$16.60 ,$19.85 ,$21.70 ,$21.70 ,$21.70 ,$8.74 ,$14.23 ,$7.12 ,$21.35 ,$17.79 ,$18.98 ,$19.69
Hoopeston Regional Hlth Center,9800257,MAXI P,,,270,$24.84 ,$24.84 ,$6.96 ,$22.73 ,$17.39 ,$20.79 ,$22.73 ,$22.73 ,$22.73 ,$9.15 ,$14.90 ,$7.45 ,$22.36 ,$18.63 ,$19.87 ,$20.62
Hoopeston Regional Hlth Center,9800258,SENSOR NEONATAL OXISENSOR,,,270,$81.06 ,$81.06 ,$22.70 ,$74.17 ,$56.74 ,$67.85 ,$74.17 ,$74.17 ,$74.17 ,$29.87 ,$48.64 ,$24.32 ,$72.95 ,$60.80 ,$64.85 ,$67.28
Hoopeston Regional Hlth Center,9800259,NEEDLE 27 5/8,,,270,$1.92 ,$1.92 ,$0.54 ,$1.76 ,$1.34 ,$1.61 ,$1.76 ,$1.76 ,$1.76 ,$0.71 ,$1.15 ,$0.58 ,$1.73 ,$1.44 ,$1.54 ,$1.59
Hoopeston Regional Hlth Center,9800260,NEEDLE GRIPPER 19G X.11/4IN,,,270,$14.88 ,$14.88 ,$4.17 ,$13.62 ,$10.42 ,$12.45 ,$13.62 ,$13.62 ,$13.62 ,$5.48 ,$8.93 ,$4.46 ,$13.39 ,$11.16 ,$11.90 ,$12.35
Hoopeston Regional Hlth Center,9800261,CPAP MASK FULL FACE,,,270,$104.50 ,$104.50 ,$29.26 ,$95.62 ,$73.15 ,$87.47 ,$95.62 ,$95.62 ,$95.62 ,$38.51 ,$62.70 ,$31.35 ,$94.05 ,$78.38 ,$83.60 ,$86.74
Hoopeston Regional Hlth Center,9800262,CO2 DETECTOR ADULT,,,270,$148.68 ,$148.68 ,$41.63 ,$136.04 ,$104.08 ,$124.45 ,$136.04 ,$136.04 ,$136.04 ,$54.79 ,$89.21 ,$44.60 ,$133.81 ,$111.51 ,$118.94 ,$123.40
Hoopeston Regional Hlth Center,9800263,CO2 DETECTOR PEDS,,,270,$148.68 ,$148.68 ,$41.63 ,$136.04 ,$104.08 ,$124.45 ,$136.04 ,$136.04 ,$136.04 ,$54.79 ,$89.21 ,$44.60 ,$133.81 ,$111.51 ,$118.94 ,$123.40
Hoopeston Regional Hlth Center,9800264,"PENROSE DRAIN .25""",,,270,$3.32 ,$3.32 ,$0.93 ,$3.04 ,$2.32 ,$2.78 ,$3.04 ,$3.04 ,$3.04 ,$1.22 ,$1.99 ,$1.00 ,$2.99 ,$2.49 ,$2.66 ,$2.76
Hoopeston Regional Hlth Center,9800265,"PENROSE DRAIN .5""",,,270,$4.60 ,$4.60 ,$1.29 ,$4.21 ,$3.22 ,$3.85 ,$4.21 ,$4.21 ,$4.21 ,$1.70 ,$2.76 ,$1.38 ,$4.14 ,$3.45 ,$3.68 ,$3.82
Hoopeston Regional Hlth Center,9800266,MASK NONREBREATHER,,,270,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9800267,INFUSION SET,,,270,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9000203,CANISTER 1200CC,,,270,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9000204,CANES,,,270,$36.52 ,$36.52 ,$10.23 ,$33.42 ,$25.56 ,$30.57 ,$33.42 ,$33.42 ,$33.42 ,$13.46 ,$21.91 ,$10.96 ,$32.87 ,$27.39 ,$29.22 ,$30.31
Hoopeston Regional Hlth Center,9800268,CANES,,,270,$36.52 ,$36.52 ,$10.23 ,$33.42 ,$25.56 ,$30.57 ,$33.42 ,$33.42 ,$33.42 ,$13.46 ,$21.91 ,$10.96 ,$32.87 ,$27.39 ,$29.22 ,$30.31
Hoopeston Regional Hlth Center,9800269,SIMPLE MASK,,,270,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9800078,CANISTER 1200CC,,,270,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9000217,DAILY OSTOMY SUPPLY,,,270,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,7624997,Cebatrol,,99070,270,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,7624996,Melamix,,99070,270,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,7624995,Melamin,,99070,270,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,7624994,Glycogent,,99070,270,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,7624993,Balatone,,99070,270,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,7624992,Foamacleanse,,99070,270,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,7624991,Normacleanse,,99070,270,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,7624990,Skincare Biocorneum 50g,,99070,270,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,7624989,Skincare Biocorneum 20g,,99070,270,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,7550009,Vaginal Dilator Large,,99070,270,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,7550010,Vaginal Dilator Med,,99070,270,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,7550770,Vaginal Dilator Sm,,99070,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,7550771,Vaginal Dilator Xs,,99070,270,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,8980270,pH test 15 feet,3052620,,270,$55.69 ,$55.69 ,$15.59 ,$50.96 ,$38.98 ,$46.61 ,$50.96 ,$50.96 ,$50.96 ,$20.52 ,$33.41 ,$16.71 ,$50.12 ,$41.77 ,$44.55 ,$46.22
Hoopeston Regional Hlth Center,8140055,SET GENESYS HTA PROCERVA 5/BX,115356,,270,"$6,241.50 ","$6,241.50 ","$1,747.62 ","$5,710.97 ","$4,369.05 ","$5,224.14 ","$5,710.97 ","$5,710.97 ","$5,710.97 ","$2,299.99 ","$3,744.90 ","$1,872.45 ","$5,617.35 ","$4,681.13 ","$4,993.20 ","$5,180.45 "
Hoopeston Regional Hlth Center,8140062,SUTURE 0 PDS CT-1 27IN Z340H,1472,,270,$9.29 ,$9.29 ,$2.60 ,$8.50 ,$6.50 ,$7.78 ,$8.50 ,$8.50 ,$8.50 ,$3.42 ,$5.57 ,$2.79 ,$8.36 ,$6.97 ,$7.43 ,$7.71
Hoopeston Regional Hlth Center,7550441,Pessary Gelhorn 1 3/4 In,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550442,Pessary Gelhorn 2 Inch,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550443,Pessary Gelhorn 2 1/4 In,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550444,Pessary Gelhorn 2 1/2 In,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550445,Pessary Gelhorn 2 3/4,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550446,Pessary Gelhorn 3 Inch,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550555,Pessary Gelhorn 3 1/2 In,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550556,Pessary Gelhorn 1 1/2 In,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550675,Pessary Gelhorn Short 1.5,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550766,Pessary Gelhorn Shrt 1.75,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550870,Pessary Gelhorn Shrt 2.5,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550872,Pessary Gelhorn Shrt 2in,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550942,Pessary Gelhorn 3 1/4 In,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7550943,Pessary Gelhorn Shrt 2.25,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7577697,Pessary Gelhorn Shrt 2.75,,A4562,271,$214.00 ,$214.00 ,$59.92 ,$195.81 ,$149.80 ,$179.12 ,$195.81 ,$195.81 ,$195.81 ,$78.86 ,$128.40 ,$64.20 ,$192.60 ,$160.50 ,$171.20 ,$177.62
Hoopeston Regional Hlth Center,7577888,Pessary Gelhorn Shrt 3.25,,A4562,271,$221.00 ,$221.00 ,$61.88 ,$202.22 ,$154.70 ,$184.98 ,$202.22 ,$202.22 ,$202.22 ,$81.44 ,$132.60 ,$66.30 ,$198.90 ,$165.75 ,$176.80 ,$183.43
Hoopeston Regional Hlth Center,9800034,MORGAN LENS,,,272,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9800035,TRAUMA PELVIC RESTRAINT,,,272,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9800036,RUSCH NASAL TUBE 2 & 3,,,272,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9800037,SUTURE,,,272,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,9800038,SPLASHCAPS,,,272,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800039,ORTHO SHOE,,,272,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9800040,SUTURE/SIMPLE,,,272,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9800041,STAPLER KIT-SKIN 15MM,,,272,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9800042,PISTON IRRIGATION TRAY,,,272,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9800043,PNEUMOTHORAX KIT,,,272,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9800044,BARIATRIC IO NEEDLE,,,272,$670.00 ,$670.00 ,$187.60 ,$613.05 ,$469.00 ,$560.79 ,$613.05 ,$613.05 ,$613.05 ,$246.90 ,$402.00 ,$201.00 ,$603.00 ,$502.50 ,$536.00 ,$556.10
Hoopeston Regional Hlth Center,9800045,IO NEEDLE STABILIZER,,,272,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9800046,NOSE SPLINT,,,272,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9800047,DRY SUCTION CHEST DRAIN,,,272,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9800048,SUTURE TRAY-MAJOR,,,272,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9800049,MINOR INSTRUMENT TRAY,,,272,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9800050,THORACENTESIS TRAY,,,272,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9800051,TROCAR CATHETERS,,,272,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9800052,C VENOUS CATH C GLOV,,,272,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9800053,THORACIC CATHETER,,,272,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9800054,CRICOTHYROIDOTOMY KIT,,,272,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,9800055,PERICARDIOCENTESIS TRAY,,,272,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9800056,CHEST TUBE TRAY,,,272,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,9800057,COMBIGUARD II IRRIGATION SPASH GUARD,,,272,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9800058,PARACENTESIS TRAY,,,272,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9800059,DENTAL EMERGENCY KIT ADULT,,,272,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9800060,DENTAL EMERGENCY KIT ADULT,,,272,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9920004,SILICONE CATHETER 16FR/5CC,,,272,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9920005,DRESSING 3X8 ADAPTIC,,,272,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9920006,LIQUI BAND SKIN ADHESIVE,,,272,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9920007,THORACENTESIS TRAY,,,272,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,9920008,SUMP DRAIN,,,272,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9920009,TROCAR CATHETERS,,,272,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9920010,INCONTINENT,,,272,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9920011,NURSING HOME ACCUCHECK,,,272,$7.00 ,$7.00 ,$1.96 ,$6.41 ,$4.90 ,$5.86 ,$6.41 ,$6.41 ,$6.41 ,$2.58 ,$4.20 ,$2.10 ,$6.30 ,$5.25 ,$5.60 ,$5.81
Hoopeston Regional Hlth Center,9920012,SUCTION SETUP,,,272,$87.00 ,$87.00 ,$24.36 ,$79.61 ,$60.90 ,$72.82 ,$79.61 ,$79.61 ,$79.61 ,$32.06 ,$52.20 ,$26.10 ,$78.30 ,$65.25 ,$69.60 ,$72.21
Hoopeston Regional Hlth Center,9920013,DEBRIDEMENT SET STERILE,,,272,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9920014,STOCKINETTE-STERILE,,,272,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9920015,THORACIC CATHETER,,,272,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9920016,CAUTERY PENCILS,,,272,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9920017,CENTRAL LINE SINGLE LUMEN,,,272,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9920018,DUODERM 4X4,,,272,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9403005,SITE RITE,,,272,$3.00 ,$3.00 ,$0.84 ,$2.75 ,$2.10 ,$2.51 ,$2.75 ,$2.75 ,$2.75 ,$1.11 ,$1.80 ,$0.90 ,$2.70 ,$2.25 ,$2.40 ,$2.49
Hoopeston Regional Hlth Center,9403006,CATHETER - PICC 4,,C1751,272,$782.00 ,$782.00 ,$218.96 ,$715.53 ,$547.40 ,$654.53 ,$715.53 ,$715.53 ,$715.53 ,$288.17 ,$469.20 ,$234.60 ,$703.80 ,$586.50 ,$625.60 ,$649.06
Hoopeston Regional Hlth Center,9403007,CATHETER - PICC 5,,C1751,272,$819.00 ,$819.00 ,$229.32 ,$749.39 ,$573.30 ,$685.50 ,$749.39 ,$749.39 ,$749.39 ,$301.80 ,$491.40 ,$245.70 ,$737.10 ,$614.25 ,$655.20 ,$679.77
Hoopeston Regional Hlth Center,9403008,INTRODUCER,,C1894,272,$124.00 ,$124.00 ,$34.72 ,$113.46 ,$86.80 ,$103.79 ,$113.46 ,$113.46 ,$113.46 ,$45.69 ,$74.40 ,$37.20 ,$111.60 ,$93.00 ,$99.20 ,$102.92
Hoopeston Regional Hlth Center,9403012,3CG - 4,,C1751,272,$952.00 ,$952.00 ,$266.56 ,$871.08 ,$666.40 ,$796.82 ,$871.08 ,$871.08 ,$871.08 ,$350.81 ,$571.20 ,$285.60 ,$856.80 ,$714.00 ,$761.60 ,$790.16
Hoopeston Regional Hlth Center,9403013,3CG - 5,,C1751,272,"$1,009.00 ","$1,009.00 ",$282.52 ,$923.24 ,$706.30 ,$844.53 ,$923.24 ,$923.24 ,$923.24 ,$371.82 ,$605.40 ,$302.70 ,$908.10 ,$756.75 ,$807.20 ,$837.47
Hoopeston Regional Hlth Center,9100170,GENERAL ANESTHESIA SUPPLIES,,,272,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9100171,MAC ANESTHESIA SUPPLIES,,,272,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9100172,SPINAL/EPIDURAL SUPPLIES,,,272,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9100173,GENERAL ANESTHESIA MEDS,,,272,$820.00 ,$820.00 ,$229.60 ,$750.30 ,$574.00 ,$686.34 ,$750.30 ,$750.30 ,$750.30 ,$302.17 ,$492.00 ,$246.00 ,$738.00 ,$615.00 ,$656.00 ,$680.60
Hoopeston Regional Hlth Center,9100174,MAC ANESTHESIA MEDS,,,272,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9100175,SPINAL/EPIDURAL MEDS,,,272,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9730002,PT THERABAND,,,272,$13.00 ,$13.00 ,$3.64 ,$11.90 ,$9.10 ,$10.88 ,$11.90 ,$11.90 ,$11.90 ,$4.79 ,$7.80 ,$3.90 ,$11.70 ,$9.75 ,$10.40 ,$10.79
Hoopeston Regional Hlth Center,9000164,FEMALE SPECI-KIT,,,272,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9100176,REGIONAL BLOCK ANESTHESIA BILLABLE SUPPLIES,,,272,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,9100177,POSTOP PAIN CONTROL BILLABLE SUPPLIES,,,272,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9100178,REGIONAL BLOCK MEDS,,,272,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9100154,CATH ROBINSON 20FR RED RUBBER STE,100,,272,$2.89 ,$2.89 ,$0.81 ,$2.64 ,$2.02 ,$2.42 ,$2.64 ,$2.64 ,$2.64 ,$1.06 ,$1.73 ,$0.87 ,$2.60 ,$2.17 ,$2.31 ,$2.40
Hoopeston Regional Hlth Center,9100154,DRAPE IOBAN INCISE 23 X 33IN,1007,,272,$41.71 ,$41.71 ,$11.68 ,$38.16 ,$29.20 ,$34.91 ,$38.16 ,$38.16 ,$38.16 ,$15.37 ,$25.03 ,$12.51 ,$37.54 ,$31.28 ,$33.37 ,$34.62
Hoopeston Regional Hlth Center,9100154,SET CYSTOSCOPY/IRRIGATION,10088,,272,$19.15 ,$19.15 ,$5.36 ,$17.52 ,$13.41 ,$16.03 ,$17.52 ,$17.52 ,$17.52 ,$7.06 ,$11.49 ,$5.75 ,$17.24 ,$14.36 ,$15.32 ,$15.89
Hoopeston Regional Hlth Center,9100154,DRESSING TELFA 2 X 3IN 100/BX LAT,10089,,272,$0.20 ,$0.20 ,$0.06 ,$0.18 ,$0.14 ,$0.17 ,$0.18 ,$0.18 ,$0.18 ,$0.07 ,$0.12 ,$0.06 ,$0.18 ,$0.15 ,$0.16 ,$0.17
Hoopeston Regional Hlth Center,9100154,CATH ROBINSON 22FR RED RUBBER STE,101,,272,$2.89 ,$2.89 ,$0.81 ,$2.64 ,$2.02 ,$2.42 ,$2.64 ,$2.64 ,$2.64 ,$1.06 ,$1.73 ,$0.87 ,$2.60 ,$2.17 ,$2.31 ,$2.40
Hoopeston Regional Hlth Center,9100154,STOCKINET IMPERVIOUS 14 X 48IN,1011,,272,$21.39 ,$21.39 ,$5.99 ,$19.57 ,$14.97 ,$17.90 ,$19.57 ,$19.57 ,$19.57 ,$7.88 ,$12.83 ,$6.42 ,$19.25 ,$16.04 ,$17.11 ,$17.75
Hoopeston Regional Hlth Center,9100154,STOCKINET COTTON 6 X 60IN,1013,,272,$14.34 ,$14.34 ,$4.02 ,$13.12 ,$10.04 ,$12.00 ,$13.12 ,$13.12 ,$13.12 ,$5.28 ,$8.60 ,$4.30 ,$12.91 ,$10.76 ,$11.47 ,$11.90
Hoopeston Regional Hlth Center,9100154,BALLOON ESOPH DIL 10-11-12MM,10191,,272,$697.50 ,$697.50 ,$195.30 ,$638.21 ,$488.25 ,$583.81 ,$638.21 ,$638.21 ,$638.21 ,$257.03 ,$418.50 ,$209.25 ,$627.75 ,$523.13 ,$558.00 ,$578.93
Hoopeston Regional Hlth Center,9100154,CATH ROBINSON 8FR RED RUBBER STER,102,,272,$2.89 ,$2.89 ,$0.81 ,$2.64 ,$2.02 ,$2.42 ,$2.64 ,$2.64 ,$2.64 ,$1.06 ,$1.73 ,$0.87 ,$2.60 ,$2.17 ,$2.31 ,$2.40
Hoopeston Regional Hlth Center,9100154,SURGICELL NU-KNIT 3 X 4IN,1027,,272,$233.72 ,$233.72 ,$65.44 ,$213.85 ,$163.60 ,$195.62 ,$213.85 ,$213.85 ,$213.85 ,$86.13 ,$140.23 ,$70.12 ,$210.35 ,$175.29 ,$186.98 ,$193.99
Hoopeston Regional Hlth Center,9100154,SURGICELL 4 X 8IN,1029,,272,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9100154,CATH FOLEY SILICONE 14FR 10CC,103,,272,$12.93 ,$12.93 ,$3.62 ,$11.83 ,$9.05 ,$10.82 ,$11.83 ,$11.83 ,$11.83 ,$4.76 ,$7.76 ,$3.88 ,$11.64 ,$9.70 ,$10.34 ,$10.73
Hoopeston Regional Hlth Center,9100154,SURGICELL 2 X 14IN,1031,,272,$252.78 ,$252.78 ,$70.78 ,$231.29 ,$176.95 ,$211.58 ,$231.29 ,$231.29 ,$231.29 ,$93.15 ,$151.67 ,$75.83 ,$227.50 ,$189.59 ,$202.22 ,$209.81
Hoopeston Regional Hlth Center,9100154,CATH FOLEY SILICONE 16FR 10CC,104,,272,$12.93 ,$12.93 ,$3.62 ,$11.83 ,$9.05 ,$10.82 ,$11.83 ,$11.83 ,$11.83 ,$4.76 ,$7.76 ,$3.88 ,$11.64 ,$9.70 ,$10.34 ,$10.73
Hoopeston Regional Hlth Center,9100154,WRAP COFLEX 4IN,1040,,272,$5.47 ,$5.47 ,$1.53 ,$5.01 ,$3.83 ,$4.58 ,$5.01 ,$5.01 ,$5.01 ,$2.02 ,$3.28 ,$1.64 ,$4.92 ,$4.10 ,$4.38 ,$4.54
Hoopeston Regional Hlth Center,9100154,APPLICATOR FLOSEAL ENDOSCOPIC,10433,,272,$273.99 ,$273.99 ,$76.72 ,$250.70 ,$191.79 ,$229.33 ,$250.70 ,$250.70 ,$250.70 ,$100.97 ,$164.39 ,$82.20 ,$246.59 ,$205.49 ,$219.19 ,$227.41
Hoopeston Regional Hlth Center,9100003,SUTURE ENDOLOOP COATED VICRYL,10434,,272,$137.09 ,$137.09 ,$38.39 ,$125.44 ,$95.96 ,$114.74 ,$125.44 ,$125.44 ,$125.44 ,$50.52 ,$82.25 ,$41.13 ,$123.38 ,$102.82 ,$109.67 ,$113.78
Hoopeston Regional Hlth Center,9100154,CATHETER BALLOON ABLATION THERMAC,1044,,272,"$6,159.92 ","$6,159.92 ","$1,724.78 ","$5,636.33 ","$4,311.94 ","$5,155.85 ","$5,636.33 ","$5,636.33 ","$5,636.33 ","$2,269.93 ","$3,695.95 ","$1,847.98 ","$5,543.93 ","$4,619.94 ","$4,927.94 ","$5,112.73 "
Hoopeston Regional Hlth Center,9100003,SYRINGE TRYPAN BLUE,10454,,272,$523.50 ,$523.50 ,$146.58 ,$479.00 ,$366.45 ,$438.17 ,$479.00 ,$479.00 ,$479.00 ,$192.91 ,$314.10 ,$157.05 ,$471.15 ,$392.63 ,$418.80 ,$434.51
Hoopeston Regional Hlth Center,9100154,CANNULA ANTERIOR CHAMBER 27GA,10456,,272,$21.56 ,$21.56 ,$6.04 ,$19.73 ,$15.09 ,$18.05 ,$19.73 ,$19.73 ,$19.73 ,$7.94 ,$12.94 ,$6.47 ,$19.40 ,$16.17 ,$17.25 ,$17.89
Hoopeston Regional Hlth Center,9100154,CATH FOLEY SILICONE 18FR 10CC,105,,272,$12.93 ,$12.93 ,$3.62 ,$11.83 ,$9.05 ,$10.82 ,$11.83 ,$11.83 ,$11.83 ,$4.76 ,$7.76 ,$3.88 ,$11.64 ,$9.70 ,$10.34 ,$10.73
Hoopeston Regional Hlth Center,9100154,CUFF TOURNIQUET 30IN 10/BX,1052,,272,$112.18 ,$112.18 ,$31.41 ,$102.64 ,$78.53 ,$93.89 ,$102.64 ,$102.64 ,$102.64 ,$41.34 ,$67.31 ,$33.65 ,$100.96 ,$84.14 ,$89.74 ,$93.11
Hoopeston Regional Hlth Center,9100154,DRESSING TEGADERM 4 X 4.75 50/BX,1056,,272,$10.60 ,$10.60 ,$2.97 ,$9.70 ,$7.42 ,$8.87 ,$9.70 ,$9.70 ,$9.70 ,$3.91 ,$6.36 ,$3.18 ,$9.54 ,$7.95 ,$8.48 ,$8.80
Hoopeston Regional Hlth Center,9100154,DRAPE TOWEL ADHESIVE,1057,,272,$2.27 ,$2.27 ,$0.64 ,$2.08 ,$1.59 ,$1.90 ,$2.08 ,$2.08 ,$2.08 ,$0.84 ,$1.36 ,$0.68 ,$2.04 ,$1.70 ,$1.82 ,$1.88
Hoopeston Regional Hlth Center,9100154,CATH FOLEY SILICONE 20FR 10ML,106,,272,$12.68 ,$12.68 ,$3.55 ,$11.60 ,$8.88 ,$10.61 ,$11.60 ,$11.60 ,$11.60 ,$4.67 ,$7.61 ,$3.80 ,$11.41 ,$9.51 ,$10.14 ,$10.52
Hoopeston Regional Hlth Center,9100154,MIRENA IUD LEVONORGESTREL 52MG,106831,,272,"$1,479.47 ","$1,479.47 ",$414.25 ,"$1,353.72 ","$1,035.63 ","$1,238.32 ","$1,353.72 ","$1,353.72 ","$1,353.72 ",$545.18 ,$887.68 ,$443.84 ,"$1,331.52 ","$1,109.60 ","$1,183.58 ","$1,227.96 "
Hoopeston Regional Hlth Center,9100154,CATH FOLEY SILICONE 22FR 30CC,107,,272,$16.26 ,$16.26 ,$4.55 ,$14.88 ,$11.38 ,$13.61 ,$14.88 ,$14.88 ,$14.88 ,$5.99 ,$9.76 ,$4.88 ,$14.63 ,$12.20 ,$13.01 ,$13.50
Hoopeston Regional Hlth Center,9100154,TUBING INSUFFLATION,1070,,272,$19.04 ,$19.04 ,$5.33 ,$17.42 ,$13.33 ,$15.94 ,$17.42 ,$17.42 ,$17.42 ,$7.02 ,$11.42 ,$5.71 ,$17.14 ,$14.28 ,$15.23 ,$15.80
Hoopeston Regional Hlth Center,9100154,PIN ODYSSEY COLLAR THREADED 2/STE,107255,,272,$603.00 ,$603.00 ,$168.84 ,$551.75 ,$422.10 ,$504.71 ,$551.75 ,$551.75 ,$551.75 ,$222.21 ,$361.80 ,$180.90 ,$542.70 ,$452.25 ,$482.40 ,$500.49
Hoopeston Regional Hlth Center,9100154,GUIDE PROPHECY ALIGNMENT 2 GUIDES,107256,,272,"$3,375.00 ","$3,375.00 ",$945.00 ,"$3,088.13 ","$2,362.50 ","$2,824.88 ","$3,088.13 ","$3,088.13 ","$3,088.13 ","$1,243.69 ","$2,025.00 ","$1,012.50 ","$3,037.50 ","$2,531.25 ","$2,700.00 ","$2,801.25 "
Hoopeston Regional Hlth Center,9100154,CATH SUCT 14FR W/GLOVE,110,,272,$1.97 ,$1.97 ,$0.55 ,$1.80 ,$1.38 ,$1.65 ,$1.80 ,$1.80 ,$1.80 ,$0.73 ,$1.18 ,$0.59 ,$1.77 ,$1.48 ,$1.58 ,$1.64
Hoopeston Regional Hlth Center,9100154,CLIP INSTINCT HEMOCLIP,110224,,272,$540.00 ,$540.00 ,$151.20 ,$494.10 ,$378.00 ,$451.98 ,$494.10 ,$494.10 ,$494.10 ,$198.99 ,$324.00 ,$162.00 ,$486.00 ,$405.00 ,$432.00 ,$448.20
Hoopeston Regional Hlth Center,9100154,CAUTERY TIP EZ CLEAN 0012 USE #30,11040,,272,$13.57 ,$13.57 ,$3.80 ,$12.42 ,$9.50 ,$11.36 ,$12.42 ,$12.42 ,$12.42 ,$5.00 ,$8.14 ,$4.07 ,$12.21 ,$10.18 ,$10.86 ,$11.26
Hoopeston Regional Hlth Center,9100154,NEEDLE CAUTERY BIPOLAR ERASER,11041,,272,$217.22 ,$217.22 ,$60.82 ,$198.76 ,$152.05 ,$181.81 ,$198.76 ,$198.76 ,$198.76 ,$80.05 ,$130.33 ,$65.17 ,$195.50 ,$162.92 ,$173.78 ,$180.29
Hoopeston Regional Hlth Center,9100154,WIPE INSTRUMENT MICRO 3.5IN 48/BX,11045,,272,$13.38 ,$13.38 ,$3.75 ,$12.24 ,$9.37 ,$11.20 ,$12.24 ,$12.24 ,$12.24 ,$4.93 ,$8.03 ,$4.01 ,$12.04 ,$10.04 ,$10.70 ,$11.11
Hoopeston Regional Hlth Center,9100154,PORT GEL LAPARSCOPIC HAND ASSIST,11049,,272,"$2,362.50 ","$2,362.50 ",$661.50 ,"$2,161.69 ","$1,653.75 ","$1,977.41 ","$2,161.69 ","$2,161.69 ","$2,161.69 ",$870.58 ,"$1,417.50 ",$708.75 ,"$2,126.25 ","$1,771.88 ","$1,890.00 ","$1,960.88 "
Hoopeston Regional Hlth Center,9100154,KIT COLOSTOMY CUT TO FIT 2 3/4 OS,11051,,272,$8.88 ,$8.88 ,$2.49 ,$8.13 ,$6.22 ,$7.43 ,$8.13 ,$8.13 ,$8.13 ,$3.27 ,$5.33 ,$2.66 ,$7.99 ,$6.66 ,$7.10 ,$7.37
Hoopeston Regional Hlth Center,9100154,KIT COLOSTOMY 2 1/4 OSTOMY 5/BX,11052,,272,$17.67 ,$17.67 ,$4.95 ,$16.17 ,$12.37 ,$14.79 ,$16.17 ,$16.17 ,$16.17 ,$6.51 ,$10.60 ,$5.30 ,$15.90 ,$13.25 ,$14.14 ,$14.67
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 VICRYL REEL J286G,11109,,272,$7.95 ,$7.95 ,$2.23 ,$7.27 ,$5.57 ,$6.65 ,$7.27 ,$7.27 ,$7.27 ,$2.93 ,$4.77 ,$2.39 ,$7.16 ,$5.96 ,$6.36 ,$6.60
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 VICRYL REEL,11110,,272,$7.80 ,$7.80 ,$2.18 ,$7.14 ,$5.46 ,$6.53 ,$7.14 ,$7.14 ,$7.14 ,$2.87 ,$4.68 ,$2.34 ,$7.02 ,$5.85 ,$6.24 ,$6.47
Hoopeston Regional Hlth Center,9100003,SUT 4-0 ETHILON PS-2,11113,,272,$14.41 ,$14.41 ,$4.03 ,$13.19 ,$10.09 ,$12.06 ,$13.19 ,$13.19 ,$13.19 ,$5.31 ,$8.65 ,$4.32 ,$12.97 ,$10.81 ,$11.53 ,$11.96
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 PROLENE SH,11122,,272,$12.22 ,$12.22 ,$3.42 ,$11.18 ,$8.55 ,$10.23 ,$11.18 ,$11.18 ,$11.18 ,$4.50 ,$7.33 ,$3.67 ,$11.00 ,$9.17 ,$9.78 ,$10.14
Hoopeston Regional Hlth Center,9100003,SUT 6-0 CHROMIC G-1,11158,,272,$34.40 ,$34.40 ,$9.63 ,$31.48 ,$24.08 ,$28.79 ,$31.48 ,$31.48 ,$31.48 ,$12.68 ,$20.64 ,$10.32 ,$30.96 ,$25.80 ,$27.52 ,$28.55
Hoopeston Regional Hlth Center,9100154,PACK GYNE LAP CASC 4/CA,11164,,272,$124.43 ,$124.43 ,$34.84 ,$113.85 ,$87.10 ,$104.15 ,$113.85 ,$113.85 ,$113.85 ,$45.85 ,$74.66 ,$37.33 ,$111.99 ,$93.32 ,$99.54 ,$103.28
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 VICRYL PS-2 J426H,11211,,272,$15.25 ,$15.25 ,$4.27 ,$13.95 ,$10.68 ,$12.76 ,$13.95 ,$13.95 ,$13.95 ,$5.62 ,$9.15 ,$4.58 ,$13.73 ,$11.44 ,$12.20 ,$12.66
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 VICRYL P-3 J494H,11213,,272,$17.76 ,$17.76 ,$4.97 ,$16.25 ,$12.43 ,$14.87 ,$16.25 ,$16.25 ,$16.25 ,$6.54 ,$10.66 ,$5.33 ,$15.98 ,$13.32 ,$14.21 ,$14.74
Hoopeston Regional Hlth Center,9100154,CUTTER ARTHRO AGGRESS PLUS 5.0,11219,,272,$234.94 ,$234.94 ,$65.78 ,$214.97 ,$164.46 ,$196.64 ,$214.97 ,$214.97 ,$214.97 ,$86.58 ,$140.96 ,$70.48 ,$211.45 ,$176.21 ,$187.95 ,$195.00
Hoopeston Regional Hlth Center,9100154,STAPLER 75MM LINEAR CUTTER 3/BX,1123,,272,$497.13 ,$497.13 ,$139.20 ,$454.87 ,$347.99 ,$416.10 ,$454.87 ,$454.87 ,$454.87 ,$183.19 ,$298.28 ,$149.14 ,$447.42 ,$372.85 ,$397.70 ,$412.62
Hoopeston Regional Hlth Center,9100154,CARTRIDGE RELOAD BLUE 75MM 12/BX,1124,,272,$265.11 ,$265.11 ,$74.23 ,$242.58 ,$185.58 ,$221.90 ,$242.58 ,$242.58 ,$242.58 ,$97.69 ,$159.07 ,$79.53 ,$238.60 ,$198.83 ,$212.09 ,$220.04
Hoopeston Regional Hlth Center,9100154,PACK LAPARAOSCOPY,11244,,272,$26.41 ,$26.41 ,$7.39 ,$24.17 ,$18.49 ,$22.11 ,$24.17 ,$24.17 ,$24.17 ,$9.73 ,$15.85 ,$7.92 ,$23.77 ,$19.81 ,$21.13 ,$21.92
Hoopeston Regional Hlth Center,9100154,DRAPE LITHOTOMY,11246,,272,$50.91 ,$50.91 ,$14.25 ,$46.58 ,$35.64 ,$42.61 ,$46.58 ,$46.58 ,$46.58 ,$18.76 ,$30.55 ,$15.27 ,$45.82 ,$38.18 ,$40.73 ,$42.26
Hoopeston Regional Hlth Center,9100154,STOCKINET IMPERVIOUS XLARGE 40/CA,11260,,272,$12.11 ,$12.11 ,$3.39 ,$11.08 ,$8.48 ,$10.14 ,$11.08 ,$11.08 ,$11.08 ,$4.46 ,$7.27 ,$3.63 ,$10.90 ,$9.08 ,$9.69 ,$10.05
Hoopeston Regional Hlth Center,9100003,SUTURE 1 VICRYL CTD CT-1 J347H,11270,,272,$9.15 ,$9.15 ,$2.56 ,$8.37 ,$6.41 ,$7.66 ,$8.37 ,$8.37 ,$8.37 ,$3.37 ,$5.49 ,$2.75 ,$8.24 ,$6.86 ,$7.32 ,$7.59
Hoopeston Regional Hlth Center,9100154,DRESSING HYDROPHILIC FOAM COPA,11279,,272,$6.50 ,$6.50 ,$1.82 ,$5.95 ,$4.55 ,$5.44 ,$5.95 ,$5.95 ,$5.95 ,$2.40 ,$3.90 ,$1.95 ,$5.85 ,$4.88 ,$5.20 ,$5.40
Hoopeston Regional Hlth Center,9100154,STAPLER PROXIMATE 60MM BLUE 3/BX,1132,,272,$332.33 ,$332.33 ,$93.05 ,$304.08 ,$232.63 ,$278.16 ,$304.08 ,$304.08 ,$304.08 ,$122.46 ,$199.40 ,$99.70 ,$299.10 ,$249.25 ,$265.86 ,$275.83
Hoopeston Regional Hlth Center,9100154,CARTRIDGE BLUE PROXIMATE 60MM 12/,1133,,272,$176.67 ,$176.67 ,$49.47 ,$161.65 ,$123.67 ,$147.87 ,$161.65 ,$161.65 ,$161.65 ,$65.10 ,$106.00 ,$53.00 ,$159.00 ,$132.50 ,$141.34 ,$146.64
Hoopeston Regional Hlth Center,9100154,ADHESIVE TOPICAL SKN DERMABOND US,11341,,272,$79.80 ,$79.80 ,$22.34 ,$73.02 ,$55.86 ,$66.79 ,$73.02 ,$73.02 ,$73.02 ,$29.41 ,$47.88 ,$23.94 ,$71.82 ,$59.85 ,$63.84 ,$66.23
Hoopeston Regional Hlth Center,9100154,TROCAR KII NO-BLADE 5X150MM,1140,,272,$76.50 ,$76.50 ,$21.42 ,$70.00 ,$53.55 ,$64.03 ,$70.00 ,$70.00 ,$70.00 ,$28.19 ,$45.90 ,$22.95 ,$68.85 ,$57.38 ,$61.20 ,$63.50
Hoopeston Regional Hlth Center,9100154,TROCAR KII NO-BLADE 12X100MM,1142,,272,$94.50 ,$94.50 ,$26.46 ,$86.47 ,$66.15 ,$79.10 ,$86.47 ,$86.47 ,$86.47 ,$34.82 ,$56.70 ,$28.35 ,$85.05 ,$70.88 ,$75.60 ,$78.44
Hoopeston Regional Hlth Center,9100154,TROCAR KII NO-BLADE 5X100MM NO BA,1143,,272,$76.50 ,$76.50 ,$21.42 ,$70.00 ,$53.55 ,$64.03 ,$70.00 ,$70.00 ,$70.00 ,$28.19 ,$45.90 ,$22.95 ,$68.85 ,$57.38 ,$61.20 ,$63.50
Hoopeston Regional Hlth Center,9100154,TROCAR HASSON 12X100MM SM CONE BL,1146,,272,$94.50 ,$94.50 ,$26.46 ,$86.47 ,$66.15 ,$79.10 ,$86.47 ,$86.47 ,$86.47 ,$34.82 ,$56.70 ,$28.35 ,$85.05 ,$70.88 ,$75.60 ,$78.44
Hoopeston Regional Hlth Center,9100154,TACKER ENDO OPTIFIX 5MM,1149,,272,"$2,951.96 ","$2,951.96 ",$826.55 ,"$2,701.04 ","$2,066.37 ","$2,470.79 ","$2,701.04 ","$2,701.04 ","$2,701.04 ","$1,087.80 ","$1,771.18 ",$885.59 ,"$2,656.76 ","$2,213.97 ","$2,361.57 ","$2,450.13 "
Hoopeston Regional Hlth Center,9100154,APPLIER ENDO 5MM ML CLIPS 3/BX,1151,,272,$538.90 ,$538.90 ,$150.89 ,$493.09 ,$377.23 ,$451.06 ,$493.09 ,$493.09 ,$493.09 ,$198.58 ,$323.34 ,$161.67 ,$485.01 ,$404.18 ,$431.12 ,$447.29
Hoopeston Regional Hlth Center,9100154,APPLIER ENDO 10MM ML CLIPS 3/BX,1152,,272,$307.73 ,$307.73 ,$86.16 ,$281.57 ,$215.41 ,$257.57 ,$281.57 ,$281.57 ,$281.57 ,$113.40 ,$184.64 ,$92.32 ,$276.96 ,$230.80 ,$246.18 ,$255.42
Hoopeston Regional Hlth Center,9100154,CATCH ENDO 10MM 10/BX,1165,,272,$162.00 ,$162.00 ,$45.36 ,$148.23 ,$113.40 ,$135.59 ,$148.23 ,$148.23 ,$148.23 ,$59.70 ,$97.20 ,$48.60 ,$145.80 ,$121.50 ,$129.60 ,$134.46
Hoopeston Regional Hlth Center,9100154,STAPLER 29MM CIRCULAR STANDARD 3/,1170,,272,"$1,111.55 ","$1,111.55 ",$311.23 ,"$1,017.07 ",$778.09 ,$930.37 ,"$1,017.07 ","$1,017.07 ","$1,017.07 ",$409.61 ,$666.93 ,$333.47 ,"$1,000.40 ",$833.66 ,$889.24 ,$922.59
Hoopeston Regional Hlth Center,9100154,CATH 3-WAY 18FR 30CC LATEX,118,,272,$62.58 ,$62.58 ,$17.52 ,$57.26 ,$43.81 ,$52.38 ,$57.26 ,$57.26 ,$57.26 ,$23.06 ,$37.55 ,$18.77 ,$56.32 ,$46.94 ,$50.06 ,$51.94
Hoopeston Regional Hlth Center,9100154,CARTRIDGE GREEN PROXIMATE 60MM us,1185,,272,$213.87 ,$213.87 ,$59.88 ,$195.69 ,$149.71 ,$179.01 ,$195.69 ,$195.69 ,$195.69 ,$78.81 ,$128.32 ,$64.16 ,$192.48 ,$160.40 ,$171.10 ,$177.51
Hoopeston Regional Hlth Center,9100154,CARTRIDGE RELOAD GREEN 75MM 12/BX,1189,,272,$270.29 ,$270.29 ,$75.68 ,$247.32 ,$189.20 ,$226.23 ,$247.32 ,$247.32 ,$247.32 ,$99.60 ,$162.17 ,$81.09 ,$243.26 ,$202.72 ,$216.23 ,$224.34
Hoopeston Regional Hlth Center,9100154,CATH 3-WAY 22FR 30CC LATEX,119,,272,$37.81 ,$37.81 ,$10.59 ,$34.60 ,$26.47 ,$31.65 ,$34.60 ,$34.60 ,$34.60 ,$13.93 ,$22.69 ,$11.34 ,$34.03 ,$28.36 ,$30.25 ,$31.38
Hoopeston Regional Hlth Center,9100154,CANNULA KII 5X100MM,1198,,272,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9100154,TROCAR KII BLADED 5X100MM,1203,,272,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9100154,APPLICATOR COTTON TIP 6IN 2PK 2/P,12056,,272,$0.18 ,$0.18 ,$0.05 ,$0.16 ,$0.13 ,$0.15 ,$0.16 ,$0.16 ,$0.16 ,$0.07 ,$0.11 ,$0.05 ,$0.16 ,$0.14 ,$0.14 ,$0.15
Hoopeston Regional Hlth Center,9100154,GLOVE PROTEXIS STRL SZ 5.5 LATEX,121448,,272,$4.08 ,$4.08 ,$1.14 ,$3.73 ,$2.86 ,$3.41 ,$3.73 ,$3.73 ,$3.73 ,$1.50 ,$2.45 ,$1.22 ,$3.67 ,$3.06 ,$3.26 ,$3.39
Hoopeston Regional Hlth Center,9100154,CLIPPER HEAD UNIVERSAL,122,,272,$8.86 ,$8.86 ,$2.48 ,$8.11 ,$6.20 ,$7.42 ,$8.11 ,$8.11 ,$8.11 ,$3.26 ,$5.32 ,$2.66 ,$7.97 ,$6.65 ,$7.09 ,$7.35
Hoopeston Regional Hlth Center,9100003,SUTURE 0 VICRYL UR-6 27IN J603H,1268,,272,$6.73 ,$6.73 ,$1.88 ,$6.16 ,$4.71 ,$5.63 ,$6.16 ,$6.16 ,$6.16 ,$2.48 ,$4.04 ,$2.02 ,$6.06 ,$5.05 ,$5.38 ,$5.59
Hoopeston Regional Hlth Center,9100003,SUTURE 0 VICRYL CT 27IN J352H,1270,,272,$5.84 ,$5.84 ,$1.64 ,$5.34 ,$4.09 ,$4.89 ,$5.34 ,$5.34 ,$5.34 ,$2.15 ,$3.50 ,$1.75 ,$5.26 ,$4.38 ,$4.67 ,$4.85
Hoopeston Regional Hlth Center,9100003,SUTURE 0 VICRYL CT-1 18IN MULTI-S,1271,,272,$41.59 ,$41.59 ,$11.65 ,$38.05 ,$29.11 ,$34.81 ,$38.05 ,$38.05 ,$38.05 ,$15.33 ,$24.95 ,$12.48 ,$37.43 ,$31.19 ,$33.27 ,$34.52
Hoopeston Regional Hlth Center,9100003,SUTURE 0 VICRYL CT-1 36IN BX/36,1272,,272,$5.75 ,$5.75 ,$1.61 ,$5.26 ,$4.03 ,$4.81 ,$5.26 ,$5.26 ,$5.26 ,$2.12 ,$3.45 ,$1.73 ,$5.18 ,$4.31 ,$4.60 ,$4.77
Hoopeston Regional Hlth Center,9100003,SUTURE 0 VICRYL CT-2 27IN J270H,1273,,272,$5.90 ,$5.90 ,$1.65 ,$5.40 ,$4.13 ,$4.94 ,$5.40 ,$5.40 ,$5.40 ,$2.17 ,$3.54 ,$1.77 ,$5.31 ,$4.43 ,$4.72 ,$4.90
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 VICRYL CT 27IN J351H,1282,,272,$5.65 ,$5.65 ,$1.58 ,$5.17 ,$3.96 ,$4.73 ,$5.17 ,$5.17 ,$5.17 ,$2.08 ,$3.39 ,$1.70 ,$5.09 ,$4.24 ,$4.52 ,$4.69
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 VICRYL SH 27IN J417H,1291,,272,$5.44 ,$5.44 ,$1.52 ,$4.98 ,$3.81 ,$4.55 ,$4.98 ,$4.98 ,$4.98 ,$2.00 ,$3.26 ,$1.63 ,$4.90 ,$4.08 ,$4.35 ,$4.52
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 VICRYL UR-6 27IN J602,1294,,272,$6.82 ,$6.82 ,$1.91 ,$6.24 ,$4.77 ,$5.71 ,$6.24 ,$6.24 ,$6.24 ,$2.51 ,$4.09 ,$2.05 ,$6.14 ,$5.12 ,$5.46 ,$5.66
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 VICRYL SH 27IN J416H,1303,,272,$5.62 ,$5.62 ,$1.57 ,$5.14 ,$3.93 ,$4.70 ,$5.14 ,$5.14 ,$5.14 ,$2.07 ,$3.37 ,$1.69 ,$5.06 ,$4.22 ,$4.50 ,$4.66
Hoopeston Regional Hlth Center,9100154,TAPE FIBER 2MM MULT OF 6,131149,,272,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 VICRYL SH 27IN J415H,1312,,272,$5.61 ,$5.61 ,$1.57 ,$5.13 ,$3.93 ,$4.70 ,$5.13 ,$5.13 ,$5.13 ,$2.07 ,$3.37 ,$1.68 ,$5.05 ,$4.21 ,$4.49 ,$4.66
Hoopeston Regional Hlth Center,9100003,FIBERWIRE 1/2 CIRCLE CONV CUT,131334,,272,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9100003,SUTURE 5-0 VICRYL PS-2 18IN J495,1317,,272,$15.13 ,$15.13 ,$4.24 ,$13.84 ,$10.59 ,$12.66 ,$13.84 ,$13.84 ,$13.84 ,$5.58 ,$9.08 ,$4.54 ,$13.62 ,$11.35 ,$12.10 ,$12.56
Hoopeston Regional Hlth Center,9100154,ELECTRODE 90 DEGREE 6/BX,132210,,272,$475.09 ,$475.09 ,$133.03 ,$434.71 ,$332.56 ,$397.65 ,$434.71 ,$434.71 ,$434.71 ,$175.07 ,$285.05 ,$142.53 ,$427.58 ,$356.32 ,$380.07 ,$394.32
Hoopeston Regional Hlth Center,9100003,SUTURE 1 PROLENE CT-1 30IN 8425H,1329,,272,$9.53 ,$9.53 ,$2.67 ,$8.72 ,$6.67 ,$7.98 ,$8.72 ,$8.72 ,$8.72 ,$3.51 ,$5.72 ,$2.86 ,$8.58 ,$7.15 ,$7.62 ,$7.91
Hoopeston Regional Hlth Center,9100154,CONTAINER SPECIMEN STERILE CLIKSE,133,,272,$2.02 ,$2.02 ,$0.57 ,$1.85 ,$1.41 ,$1.69 ,$1.85 ,$1.85 ,$1.85 ,$0.74 ,$1.21 ,$0.61 ,$1.82 ,$1.52 ,$1.62 ,$1.68
Hoopeston Regional Hlth Center,9100003,SUTURE 0 PROLENE CT-2 30IN 8412H,1331,,272,$9.27 ,$9.27 ,$2.60 ,$8.48 ,$6.49 ,$7.76 ,$8.48 ,$8.48 ,$8.48 ,$3.42 ,$5.56 ,$2.78 ,$8.34 ,$6.95 ,$7.42 ,$7.69
Hoopeston Regional Hlth Center,9100003,SUTURE 0 PROLENE V-34 30IN 8444H,1332,,272,$12.12 ,$12.12 ,$3.39 ,$11.09 ,$8.48 ,$10.14 ,$11.09 ,$11.09 ,$11.09 ,$4.47 ,$7.27 ,$3.64 ,$10.91 ,$9.09 ,$9.70 ,$10.06
Hoopeston Regional Hlth Center,9100003,SUTURE 1 PROLENE CTX 30IN BX/36,1334,,272,$8.74 ,$8.74 ,$2.45 ,$8.00 ,$6.12 ,$7.32 ,$8.00 ,$8.00 ,$8.00 ,$3.22 ,$5.24 ,$2.62 ,$7.87 ,$6.56 ,$6.99 ,$7.25
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 PROLENE RB-1 36IN DOUB,1340,,272,$32.38 ,$32.38 ,$9.07 ,$29.63 ,$22.67 ,$27.10 ,$29.63 ,$29.63 ,$29.63 ,$11.93 ,$19.43 ,$9.71 ,$29.14 ,$24.29 ,$25.90 ,$26.88
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 PROLENE BB 36IN DOUBLE,1343,,272,$22.62 ,$22.62 ,$6.33 ,$20.70 ,$15.83 ,$18.93 ,$20.70 ,$20.70 ,$20.70 ,$8.34 ,$13.57 ,$6.79 ,$20.36 ,$16.97 ,$18.10 ,$18.77
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 PROLENE RB-1 36IN DOUB,1348,,272,$22.69 ,$22.69 ,$6.35 ,$20.76 ,$15.88 ,$18.99 ,$20.76 ,$20.76 ,$20.76 ,$8.36 ,$13.61 ,$6.81 ,$20.42 ,$17.02 ,$18.15 ,$18.83
Hoopeston Regional Hlth Center,9100003,SUTURE 6-0 PROLENE BV-1 30IN DOUB,1356,,272,$65.34 ,$65.34 ,$18.30 ,$59.79 ,$45.74 ,$54.69 ,$59.79 ,$59.79 ,$59.79 ,$24.08 ,$39.20 ,$19.60 ,$58.81 ,$49.01 ,$52.27 ,$54.23
Hoopeston Regional Hlth Center,9100154,DRAPE BACK TABLE COVER 50X90,136,,272,$7.44 ,$7.44 ,$2.08 ,$6.81 ,$5.21 ,$6.23 ,$6.81 ,$6.81 ,$6.81 ,$2.74 ,$4.46 ,$2.23 ,$6.70 ,$5.58 ,$5.95 ,$6.18
Hoopeston Regional Hlth Center,9100154,COVER MAYO STAND,137,,272,$3.37 ,$3.37 ,$0.94 ,$3.08 ,$2.36 ,$2.82 ,$3.08 ,$3.08 ,$3.08 ,$1.24 ,$2.02 ,$1.01 ,$3.03 ,$2.53 ,$2.70 ,$2.80
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 CHROMIC SH 27IN G122H,1383,,272,$11.35 ,$11.35 ,$3.18 ,$10.39 ,$7.95 ,$9.50 ,$10.39 ,$10.39 ,$10.39 ,$4.18 ,$6.81 ,$3.41 ,$10.22 ,$8.51 ,$9.08 ,$9.42
Hoopeston Regional Hlth Center,9100154,PASSER SUTURE CARTER THOMAS I 5/B,138498,,272,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 CHROMIC RB-1 27IN U20,1388,,272,$11.45 ,$11.45 ,$3.21 ,$10.48 ,$8.02 ,$9.58 ,$10.48 ,$10.48 ,$10.48 ,$4.22 ,$6.87 ,$3.44 ,$10.31 ,$8.59 ,$9.16 ,$9.50
Hoopeston Regional Hlth Center,9100003,SUTURE 6-0 CHROMIC G-1 18IN DOUBL,1392,,272,$64.68 ,$64.68 ,$18.11 ,$59.18 ,$45.28 ,$54.14 ,$59.18 ,$59.18 ,$59.18 ,$23.83 ,$38.81 ,$19.40 ,$58.21 ,$48.51 ,$51.74 ,$53.68
Hoopeston Regional Hlth Center,9100003,SUTURE TIES 0 SILK 30IN MS A306H,1408,,272,$5.16 ,$5.16 ,$1.44 ,$4.72 ,$3.61 ,$4.32 ,$4.72 ,$4.72 ,$4.72 ,$1.90 ,$3.10 ,$1.55 ,$4.64 ,$3.87 ,$4.13 ,$4.28
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 SILK FSL 18IN 677G,1409,,272,$6.37 ,$6.37 ,$1.78 ,$5.83 ,$4.46 ,$5.33 ,$5.83 ,$5.83 ,$5.83 ,$2.35 ,$3.82 ,$1.91 ,$5.73 ,$4.78 ,$5.10 ,$5.29
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 SILK REEL TIE LA55G,1410,,272,$6.70 ,$6.70 ,$1.88 ,$6.13 ,$4.69 ,$5.61 ,$6.13 ,$6.13 ,$6.13 ,$2.47 ,$4.02 ,$2.01 ,$6.03 ,$5.03 ,$5.36 ,$5.56
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 SILK SH 30IN K833H,1412,,272,$4.60 ,$4.60 ,$1.29 ,$4.21 ,$3.22 ,$3.85 ,$4.21 ,$4.21 ,$4.21 ,$1.70 ,$2.76 ,$1.38 ,$4.14 ,$3.45 ,$3.68 ,$3.82
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 SILK FS-1 18IN 684G,1415,,272,$7.31 ,$7.31 ,$2.05 ,$6.69 ,$5.12 ,$6.12 ,$6.69 ,$6.69 ,$6.69 ,$2.69 ,$4.39 ,$2.19 ,$6.58 ,$5.48 ,$5.85 ,$6.07
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 SILK SH 30IN MS C017D,1417,,272,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 SILK SH 30IN K832H,1418,,272,$4.60 ,$4.60 ,$1.29 ,$4.21 ,$3.22 ,$3.85 ,$4.21 ,$4.21 ,$4.21 ,$1.70 ,$2.76 ,$1.38 ,$4.14 ,$3.45 ,$3.68 ,$3.82
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 SILK 30IN TIE A303H,1422,,272,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 ETHILON FS 18IN 664H,1448,,272,$7.08 ,$7.08 ,$1.98 ,$6.48 ,$4.96 ,$5.93 ,$6.48 ,$6.48 ,$6.48 ,$2.61 ,$4.25 ,$2.12 ,$6.37 ,$5.31 ,$5.66 ,$5.88
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 ETHILON PS-1 18IN 166,1450,,272,$16.19 ,$16.19 ,$4.53 ,$14.81 ,$11.33 ,$13.55 ,$14.81 ,$14.81 ,$14.81 ,$5.97 ,$9.71 ,$4.86 ,$14.57 ,$12.14 ,$12.95 ,$13.44
Hoopeston Regional Hlth Center,9100003,SUTURE 5-0 ETHILON PS-2 18IN 166,1457,,272,$13.90 ,$13.90 ,$3.89 ,$12.72 ,$9.73 ,$11.63 ,$12.72 ,$12.72 ,$12.72 ,$5.12 ,$8.34 ,$4.17 ,$12.51 ,$10.43 ,$11.12 ,$11.54
Hoopeston Regional Hlth Center,9100003,SUTURE 6-0 ETHILON P-1 18IN 697G,1459,,272,$15.79 ,$15.79 ,$4.42 ,$14.45 ,$11.05 ,$13.22 ,$14.45 ,$14.45 ,$14.45 ,$5.82 ,$9.47 ,$4.74 ,$14.21 ,$11.84 ,$12.63 ,$13.11
Hoopeston Regional Hlth Center,9100003,SUTURE 0 PDS CT 36IN Z358T,1471,,272,$10.28 ,$10.28 ,$2.88 ,$9.41 ,$7.20 ,$8.60 ,$9.41 ,$9.41 ,$9.41 ,$3.79 ,$6.17 ,$3.08 ,$9.25 ,$7.71 ,$8.22 ,$8.53
Hoopeston Regional Hlth Center,9100003,SUTURE 0 PDS CTX 60IN Z990G,1474,,272,$20.67 ,$20.67 ,$5.79 ,$18.91 ,$14.47 ,$17.30 ,$18.91 ,$18.91 ,$18.91 ,$7.62 ,$12.40 ,$6.20 ,$18.60 ,$15.50 ,$16.54 ,$17.16
Hoopeston Regional Hlth Center,9100154,DRAIN JACKSON-PRATT ROUND 10FR,148,,272,$70.38 ,$70.38 ,$19.71 ,$64.40 ,$49.27 ,$58.91 ,$64.40 ,$64.40 ,$64.40 ,$25.94 ,$42.23 ,$21.11 ,$63.34 ,$52.79 ,$56.30 ,$58.42
Hoopeston Regional Hlth Center,9100154,ANCHOR BIOCORK STL 5.MM SWIVELOCK,148233,,272,$337.50 ,$337.50 ,$94.50 ,$308.81 ,$236.25 ,$282.49 ,$308.81 ,$308.81 ,$308.81 ,$124.37 ,$202.50 ,$101.25 ,$303.75 ,$253.13 ,$270.00 ,$280.13
Hoopeston Regional Hlth Center,9100154,DRAIN JACKSON-PRATT ROUND 15FR,149,,272,$70.38 ,$70.38 ,$19.71 ,$64.40 ,$49.27 ,$58.91 ,$64.40 ,$64.40 ,$64.40 ,$25.94 ,$42.23 ,$21.11 ,$63.34 ,$52.79 ,$56.30 ,$58.42
Hoopeston Regional Hlth Center,9100003,SUTURE 2 FIBERWIRE TAPER 38IN INC,1496,,272,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 FIBERWIRE T-13 18IN,1497,,272,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,9100154,RESERVOIR JACKSON-PRATT 100ML,150,,272,$11.39 ,$11.39 ,$3.19 ,$10.42 ,$7.97 ,$9.53 ,$10.42 ,$10.42 ,$10.42 ,$4.20 ,$6.83 ,$3.42 ,$10.25 ,$8.54 ,$9.11 ,$9.45
Hoopeston Regional Hlth Center,9100154,RESERVOIR JACKSON-PRATT 400ML,151,,272,$37.13 ,$37.13 ,$10.40 ,$33.97 ,$25.99 ,$31.08 ,$33.97 ,$33.97 ,$33.97 ,$13.68 ,$22.28 ,$11.14 ,$33.42 ,$27.85 ,$29.70 ,$30.82
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 MONOCRYL PLUS PS-2 27I,1515,,272,$24.48 ,$24.48 ,$6.85 ,$22.40 ,$17.14 ,$20.49 ,$22.40 ,$22.40 ,$22.40 ,$9.02 ,$14.69 ,$7.34 ,$22.03 ,$18.36 ,$19.58 ,$20.32
Hoopeston Regional Hlth Center,9100154,BAG URINARY DRAIN 2000ML,152,,272,$9.45 ,$9.45 ,$2.65 ,$8.65 ,$6.62 ,$7.91 ,$8.65 ,$8.65 ,$8.65 ,$3.48 ,$5.67 ,$2.84 ,$8.51 ,$7.09 ,$7.56 ,$7.84
Hoopeston Regional Hlth Center,9100154,DRAPE THREE QUARTER 60X76IN,156,,272,$7.45 ,$7.45 ,$2.09 ,$6.82 ,$5.22 ,$6.24 ,$6.82 ,$6.82 ,$6.82 ,$2.75 ,$4.47 ,$2.24 ,$6.71 ,$5.59 ,$5.96 ,$6.18
Hoopeston Regional Hlth Center,9100154,DRESSING ADAPTIC 3 X 3 NON-ADHERI,157,,272,$0.73 ,$0.73 ,$0.20 ,$0.67 ,$0.51 ,$0.61 ,$0.67 ,$0.67 ,$0.67 ,$0.27 ,$0.44 ,$0.22 ,$0.66 ,$0.55 ,$0.58 ,$0.61
Hoopeston Regional Hlth Center,9100154,DRESSING ADAPTIC 3 X 8 NON-ADHERI,158,,272,$1.77 ,$1.77 ,$0.50 ,$1.62 ,$1.24 ,$1.48 ,$1.62 ,$1.62 ,$1.62 ,$0.65 ,$1.06 ,$0.53 ,$1.59 ,$1.33 ,$1.42 ,$1.47
Hoopeston Regional Hlth Center,9100154,COVER PIN BALL .045 YELLOW 6/RL,1586,,272,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9100154,COVER PIN BALL .062 GREEN,1587,,272,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9100154,DRESSING COPA FOAM 4X4 NON-ADHERI,159,,272,$3.51 ,$3.51 ,$0.98 ,$3.21 ,$2.46 ,$2.94 ,$3.21 ,$3.21 ,$3.21 ,$1.29 ,$2.11 ,$1.05 ,$3.16 ,$2.63 ,$2.81 ,$2.91
Hoopeston Regional Hlth Center,9100154,DRESSING XEROFORM 1 X 8,163,,272,$1.31 ,$1.31 ,$0.37 ,$1.20 ,$0.92 ,$1.10 ,$1.20 ,$1.20 ,$1.20 ,$0.48 ,$0.79 ,$0.39 ,$1.18 ,$0.98 ,$1.05 ,$1.09
Hoopeston Regional Hlth Center,9100154,DRESSING TEGADERM 8X12,165,,272,$7.59 ,$7.59 ,$2.13 ,$6.94 ,$5.31 ,$6.35 ,$6.94 ,$6.94 ,$6.94 ,$2.80 ,$4.55 ,$2.28 ,$6.83 ,$5.69 ,$6.07 ,$6.30
Hoopeston Regional Hlth Center,9100154,DRESSING TEGADERM 2X3 100/BX,169,,272,$0.49 ,$0.49 ,$0.14 ,$0.45 ,$0.34 ,$0.41 ,$0.45 ,$0.45 ,$0.45 ,$0.18 ,$0.29 ,$0.15 ,$0.44 ,$0.37 ,$0.39 ,$0.41
Hoopeston Regional Hlth Center,9100154,DRESSING TELFA 3 X 8,171,,272,$0.24 ,$0.24 ,$0.07 ,$0.22 ,$0.17 ,$0.20 ,$0.22 ,$0.22 ,$0.22 ,$0.09 ,$0.14 ,$0.07 ,$0.22 ,$0.18 ,$0.19 ,$0.20
Hoopeston Regional Hlth Center,9100154,ELECTRODE MONITORING 450 FOAM 50/,172,,272,$13.60 ,$13.60 ,$3.81 ,$12.44 ,$9.52 ,$11.38 ,$12.44 ,$12.44 ,$12.44 ,$5.01 ,$8.16 ,$4.08 ,$12.24 ,$10.20 ,$10.88 ,$11.29
Hoopeston Regional Hlth Center,9100154,PAD ELECTRODE DISPERSE >4.4LB COR,174,,272,$5.41 ,$5.41 ,$1.51 ,$4.95 ,$3.79 ,$4.53 ,$4.95 ,$4.95 ,$4.95 ,$1.99 ,$3.25 ,$1.62 ,$4.87 ,$4.06 ,$4.33 ,$4.49
Hoopeston Regional Hlth Center,9100154,FORCEP BIOPSY DISP HOT,182,,272,$74.35 ,$74.35 ,$20.82 ,$68.03 ,$52.05 ,$62.23 ,$68.03 ,$68.03 ,$68.03 ,$27.40 ,$44.61 ,$22.31 ,$66.92 ,$55.76 ,$59.48 ,$61.71
Hoopeston Regional Hlth Center,9100154,BANDAGE CONFORM 3IN STRL KRLX,183,,272,$1.62 ,$1.62 ,$0.45 ,$1.48 ,$1.13 ,$1.36 ,$1.48 ,$1.48 ,$1.48 ,$0.60 ,$0.97 ,$0.49 ,$1.46 ,$1.22 ,$1.30 ,$1.34
Hoopeston Regional Hlth Center,9100154,GLOVE PROTEXIS STRL SZ 6 LATEX /,187,,272,$3.66 ,$3.66 ,$1.02 ,$3.35 ,$2.56 ,$3.06 ,$3.35 ,$3.35 ,$3.35 ,$1.35 ,$2.20 ,$1.10 ,$3.29 ,$2.75 ,$2.93 ,$3.04
Hoopeston Regional Hlth Center,9100154,FORCEP BX ALLIGATOR JAW STEP 20/B,196934,,272,$28.42 ,$28.42 ,$7.96 ,$26.00 ,$19.89 ,$23.79 ,$26.00 ,$26.00 ,$26.00 ,$10.47 ,$17.05 ,$8.53 ,$25.58 ,$21.32 ,$22.74 ,$23.59
Hoopeston Regional Hlth Center,9100154,GLOVE PROTEXIS PI LF 7.0 SYNTHETI,200,,272,$6.14 ,$6.14 ,$1.72 ,$5.62 ,$4.30 ,$5.14 ,$5.62 ,$5.62 ,$5.62 ,$2.26 ,$3.68 ,$1.84 ,$5.53 ,$4.61 ,$4.91 ,$5.10
Hoopeston Regional Hlth Center,9100154,GLOVE PROTEXIS PI LF 7.5 SYNTHETI,201,,272,$6.14 ,$6.14 ,$1.72 ,$5.62 ,$4.30 ,$5.14 ,$5.62 ,$5.62 ,$5.62 ,$2.26 ,$3.68 ,$1.84 ,$5.53 ,$4.61 ,$4.91 ,$5.10
Hoopeston Regional Hlth Center,9100154,CATHETER KUMAR CHOLANGIOGRAM BX/2,201484,,272,$151.88 ,$151.88 ,$42.53 ,$138.97 ,$106.32 ,$127.12 ,$138.97 ,$138.97 ,$138.97 ,$55.97 ,$91.13 ,$45.56 ,$136.69 ,$113.91 ,$121.50 ,$126.06
Hoopeston Regional Hlth Center,9100154,SOLUTION STRL IRR BSS 500ML,202533,,272,$27.32 ,$27.32 ,$7.65 ,$25.00 ,$19.12 ,$22.87 ,$25.00 ,$25.00 ,$25.00 ,$10.07 ,$16.39 ,$8.20 ,$24.59 ,$20.49 ,$21.86 ,$22.68
Hoopeston Regional Hlth Center,9100154,GOWN ASTOUND SURG LARGE AAMI 3,203,,272,$7.68 ,$7.68 ,$2.15 ,$7.03 ,$5.38 ,$6.43 ,$7.03 ,$7.03 ,$7.03 ,$2.83 ,$4.61 ,$2.30 ,$6.91 ,$5.76 ,$6.14 ,$6.37
Hoopeston Regional Hlth Center,9100154,PROTECTOR WOUND SMALL BX/5,203528,,272,$126.00 ,$126.00 ,$35.28 ,$115.29 ,$88.20 ,$105.46 ,$115.29 ,$115.29 ,$115.29 ,$46.43 ,$75.60 ,$37.80 ,$113.40 ,$94.50 ,$100.80 ,$104.58
Hoopeston Regional Hlth Center,9100154,PROTECTOR WOUND MEDIUM BX/5,203529,,272,$126.00 ,$126.00 ,$35.28 ,$115.29 ,$88.20 ,$105.46 ,$115.29 ,$115.29 ,$115.29 ,$46.43 ,$75.60 ,$37.80 ,$113.40 ,$94.50 ,$100.80 ,$104.58
Hoopeston Regional Hlth Center,9100154,PROTECTOR WOUND LARGE BX/5,203530,,272,$193.50 ,$193.50 ,$54.18 ,$177.05 ,$135.45 ,$161.96 ,$177.05 ,$177.05 ,$177.05 ,$71.30 ,$116.10 ,$58.05 ,$174.15 ,$145.13 ,$154.80 ,$160.61
Hoopeston Regional Hlth Center,9100154,PROTECTOR WOUND XLARGE BX/5,203531,,272,$243.00 ,$243.00 ,$68.04 ,$222.35 ,$170.10 ,$203.39 ,$222.35 ,$222.35 ,$222.35 ,$89.55 ,$145.80 ,$72.90 ,$218.70 ,$182.25 ,$194.40 ,$201.69
Hoopeston Regional Hlth Center,9100154,SNARE COLD EXACTO 9MM 10/BX,204645,,272,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9100154,GOWN SMARTGOWN LARGE AAMI 4,205,,272,$14.75 ,$14.75 ,$4.13 ,$13.50 ,$10.33 ,$12.35 ,$13.50 ,$13.50 ,$13.50 ,$5.44 ,$8.85 ,$4.43 ,$13.28 ,$11.06 ,$11.80 ,$12.24
Hoopeston Regional Hlth Center,9100154,ADHESIVE TOPICAL SKN EXOFIN 1ml /,205286,,272,$54.32 ,$54.32 ,$15.21 ,$49.70 ,$38.02 ,$45.47 ,$49.70 ,$49.70 ,$49.70 ,$20.02 ,$32.59 ,$16.30 ,$48.89 ,$40.74 ,$43.46 ,$45.09
Hoopeston Regional Hlth Center,9100154,GOWN ASTOUND XL AAMI 3,206,,272,$8.22 ,$8.22 ,$2.30 ,$7.52 ,$5.75 ,$6.88 ,$7.52 ,$7.52 ,$7.52 ,$3.03 ,$4.93 ,$2.47 ,$7.40 ,$6.17 ,$6.58 ,$6.82
Hoopeston Regional Hlth Center,9100154,CARTRIDGE GREEN PROXIMATE 60MM 12,206676,,272,$164.51 ,$164.51 ,$46.06 ,$150.53 ,$115.16 ,$137.69 ,$150.53 ,$150.53 ,$150.53 ,$60.62 ,$98.71 ,$49.35 ,$148.06 ,$123.38 ,$131.61 ,$136.54
Hoopeston Regional Hlth Center,9100154,TUBE LARYNGECTOMY PROVOX KIT,206677,,272,"$1,552.50 ","$1,552.50 ",$434.70 ,"$1,420.54 ","$1,086.75 ","$1,299.44 ","$1,420.54 ","$1,420.54 ","$1,420.54 ",$572.10 ,$931.50 ,$465.75 ,"$1,397.25 ","$1,164.38 ","$1,242.00 ","$1,288.58 "
Hoopeston Regional Hlth Center,9100154,KIT VEGA PUNCTURE PROVOX,206678,,272,"$1,705.50 ","$1,705.50 ",$477.54 ,"$1,560.53 ","$1,193.85 ","$1,427.50 ","$1,560.53 ","$1,560.53 ","$1,560.53 ",$628.48 ,"$1,023.30 ",$511.65 ,"$1,534.95 ","$1,279.13 ","$1,364.40 ","$1,415.57 "
Hoopeston Regional Hlth Center,9100154,STAY ELASTIC 12MM,20691,,272,$44.18 ,$44.18 ,$12.37 ,$40.42 ,$30.93 ,$36.98 ,$40.42 ,$40.42 ,$40.42 ,$16.28 ,$26.51 ,$13.25 ,$39.76 ,$33.14 ,$35.34 ,$36.67
Hoopeston Regional Hlth Center,9100154,MARKER GI TRACT SPOT BCMPT N-PYRG,206962,,272,$171.00 ,$171.00 ,$47.88 ,$156.47 ,$119.70 ,$143.13 ,$156.47 ,$156.47 ,$156.47 ,$63.01 ,$102.60 ,$51.30 ,$153.90 ,$128.25 ,$136.80 ,$141.93
Hoopeston Regional Hlth Center,9100154,KIT DEFENDO 5 PIECE W/CLEANING 50,207588,,272,$47.25 ,$47.25 ,$13.23 ,$43.23 ,$33.08 ,$39.55 ,$43.23 ,$43.23 ,$43.23 ,$17.41 ,$28.35 ,$14.18 ,$42.53 ,$35.44 ,$37.80 ,$39.22
Hoopeston Regional Hlth Center,9100154,BALLOON ESOPH DIL 10-11-12MM,207623,,272,$697.50 ,$697.50 ,$195.30 ,$638.21 ,$488.25 ,$583.81 ,$638.21 ,$638.21 ,$638.21 ,$257.03 ,$418.50 ,$209.25 ,$627.75 ,$523.13 ,$558.00 ,$578.93
Hoopeston Regional Hlth Center,9100154,SEALER DIVIDER ENSEAL 35CM ART BX,208542,,272,"$2,033.12 ","$2,033.12 ",$569.27 ,"$1,860.30 ","$1,423.18 ","$1,701.72 ","$1,860.30 ","$1,860.30 ","$1,860.30 ",$749.20 ,"$1,219.87 ",$609.94 ,"$1,829.81 ","$1,524.84 ","$1,626.50 ","$1,687.49 "
Hoopeston Regional Hlth Center,9100154,DEVICE SPHERE INFLATION,210642,,272,$157.50 ,$157.50 ,$44.10 ,$144.11 ,$110.25 ,$131.83 ,$144.11 ,$144.11 ,$144.11 ,$58.04 ,$94.50 ,$47.25 ,$141.75 ,$118.13 ,$126.00 ,$130.73
Hoopeston Regional Hlth Center,9100154,PENCIL CAUTERY,211319,,272,$19.84 ,$19.84 ,$5.56 ,$18.15 ,$13.89 ,$16.61 ,$18.15 ,$18.15 ,$18.15 ,$7.31 ,$11.90 ,$5.95 ,$17.86 ,$14.88 ,$15.87 ,$16.47
Hoopeston Regional Hlth Center,9100154,TIP L CAUTERY,211320,,272,$69.73 ,$69.73 ,$19.52 ,$63.80 ,$48.81 ,$58.36 ,$63.80 ,$63.80 ,$63.80 ,$25.70 ,$41.84 ,$20.92 ,$62.76 ,$52.30 ,$55.78 ,$57.88
Hoopeston Regional Hlth Center,9100154,SEALER SUPER ENSEAL 22CM,212378,,272,"$2,421.72 ","$2,421.72 ",$678.08 ,"$2,215.87 ","$1,695.20 ","$2,026.98 ","$2,215.87 ","$2,215.87 ","$2,215.87 ",$892.40 ,"$1,453.03 ",$726.52 ,"$2,179.55 ","$1,816.29 ","$1,937.38 ","$2,010.03 "
Hoopeston Regional Hlth Center,9100154,DEVICE OPTIFIX LAP 15 SHOT,214724,,272,"$1,115.62 ","$1,115.62 ",$312.37 ,"$1,020.79 ",$780.93 ,$933.77 ,"$1,020.79 ","$1,020.79 ","$1,020.79 ",$411.11 ,$669.37 ,$334.69 ,"$1,004.06 ",$836.72 ,$892.50 ,$925.96
Hoopeston Regional Hlth Center,9100154,CATHETER KUMAR CHOLANGIOGRAM BX/2,216961,,272,$157.05 ,$157.05 ,$43.97 ,$143.70 ,$109.94 ,$131.45 ,$143.70 ,$143.70 ,$143.70 ,$57.87 ,$94.23 ,$47.12 ,$141.35 ,$117.79 ,$125.64 ,$130.35
Hoopeston Regional Hlth Center,9100154,PENCIL SMOKE EVAC COATED PB 10 PE,216964,,272,$128.25 ,$128.25 ,$35.91 ,$117.35 ,$89.78 ,$107.35 ,$117.35 ,$117.35 ,$117.35 ,$47.26 ,$76.95 ,$38.48 ,$115.43 ,$96.19 ,$102.60 ,$106.45
Hoopeston Regional Hlth Center,9100154,DRESSING PRINEO DERMABOND 22CM BX,217553,,272,$352.26 ,$352.26 ,$98.63 ,$322.32 ,$246.58 ,$294.84 ,$322.32 ,$322.32 ,$322.32 ,$129.81 ,$211.36 ,$105.68 ,$317.03 ,$264.20 ,$281.81 ,$292.38
Hoopeston Regional Hlth Center,9100154,SET EXT MICROBORE CLAVE 7IN,218,,272,$10.14 ,$10.14 ,$2.84 ,$9.28 ,$7.10 ,$8.49 ,$9.28 ,$9.28 ,$9.28 ,$3.74 ,$6.08 ,$3.04 ,$9.13 ,$7.61 ,$8.11 ,$8.42
Hoopeston Regional Hlth Center,9100154,DRESSING MEPILEX BORDER 4X12 CA/2,218115,,272,$24.15 ,$24.15 ,$6.76 ,$22.10 ,$16.91 ,$20.21 ,$22.10 ,$22.10 ,$22.10 ,$8.90 ,$14.49 ,$7.25 ,$21.74 ,$18.11 ,$19.32 ,$20.04
Hoopeston Regional Hlth Center,9100154,IRRIGATOR SUCTION STRYKER FLOW,219,,272,$213.86 ,$213.86 ,$59.88 ,$195.68 ,$149.70 ,$179.00 ,$195.68 ,$195.68 ,$195.68 ,$78.81 ,$128.32 ,$64.16 ,$192.47 ,$160.40 ,$171.09 ,$177.50
Hoopeston Regional Hlth Center,9100154,POWDER SURGICELL 3.0 GRAMS use #3,219794,,272,"$1,164.58 ","$1,164.58 ",$326.08 ,"$1,065.59 ",$815.21 ,$974.75 ,"$1,065.59 ","$1,065.59 ","$1,065.59 ",$429.15 ,$698.75 ,$349.37 ,"$1,048.12 ",$873.44 ,$931.66 ,$966.60
Hoopeston Regional Hlth Center,9100154,DRESSING XEROFORM PETROLM ROLL,221979,,272,$11.66 ,$11.66 ,$3.26 ,$10.67 ,$8.16 ,$9.76 ,$10.67 ,$10.67 ,$10.67 ,$4.30 ,$7.00 ,$3.50 ,$10.49 ,$8.75 ,$9.33 ,$9.68
Hoopeston Regional Hlth Center,9100154,POWDER SURGICELL 3.0 GRAMS BX/5,225604,,272,$747.78 ,$747.78 ,$209.38 ,$684.22 ,$523.45 ,$625.89 ,$684.22 ,$684.22 ,$684.22 ,$275.56 ,$448.67 ,$224.33 ,$673.00 ,$560.84 ,$598.22 ,$620.66
Hoopeston Regional Hlth Center,9100154,MAT FLOOR GELMAX SPR ABSORB LG 10,226719,,272,$15.64 ,$15.64 ,$4.38 ,$14.31 ,$10.95 ,$13.09 ,$14.31 ,$14.31 ,$14.31 ,$5.76 ,$9.38 ,$4.69 ,$14.08 ,$11.73 ,$12.51 ,$12.98
Hoopeston Regional Hlth Center,9100154,LUBRICANT SURGICAL 4 1/4 OZ STERI,227,,272,$10.95 ,$10.95 ,$3.07 ,$10.02 ,$7.67 ,$9.17 ,$10.02 ,$10.02 ,$10.02 ,$4.04 ,$6.57 ,$3.29 ,$9.86 ,$8.21 ,$8.76 ,$9.09
Hoopeston Regional Hlth Center,9100154,SURGICELL SNOW 1X2,227126,,272,$235.61 ,$235.61 ,$65.97 ,$215.58 ,$164.93 ,$197.21 ,$215.58 ,$215.58 ,$215.58 ,$86.82 ,$141.37 ,$70.68 ,$212.05 ,$176.71 ,$188.49 ,$195.56
Hoopeston Regional Hlth Center,9100154,SURGICELL SNOW 2X4,227127,,272,$433.64 ,$433.64 ,$121.42 ,$396.78 ,$303.55 ,$362.96 ,$396.78 ,$396.78 ,$396.78 ,$159.80 ,$260.18 ,$130.09 ,$390.28 ,$325.23 ,$346.91 ,$359.92
Hoopeston Regional Hlth Center,9100154,SURGICELL SNOW 4X4,227128,,272,$542.05 ,$542.05 ,$151.77 ,$495.98 ,$379.44 ,$453.70 ,$495.98 ,$495.98 ,$495.98 ,$199.75 ,$325.23 ,$162.62 ,$487.85 ,$406.54 ,$433.64 ,$449.90
Hoopeston Regional Hlth Center,9100154,PACK DASC FOOT ANKLE 5/CA,227212,,272,$79.09 ,$79.09 ,$22.15 ,$72.37 ,$55.36 ,$66.20 ,$72.37 ,$72.37 ,$72.37 ,$29.14 ,$47.45 ,$23.73 ,$71.18 ,$59.32 ,$63.27 ,$65.64
Hoopeston Regional Hlth Center,9100154,LUBRICANT FOIL PK SURGILUBE 5 GR,228,,272,$0.26 ,$0.26 ,$0.07 ,$0.24 ,$0.18 ,$0.22 ,$0.24 ,$0.24 ,$0.24 ,$0.10 ,$0.16 ,$0.08 ,$0.23 ,$0.20 ,$0.21 ,$0.22
Hoopeston Regional Hlth Center,9100154,APPLICATOR ENDOSCOPIC SURGICEL,230133,,272,$88.21 ,$88.21 ,$24.70 ,$80.71 ,$61.75 ,$73.83 ,$80.71 ,$80.71 ,$80.71 ,$32.51 ,$52.93 ,$26.46 ,$79.39 ,$66.16 ,$70.57 ,$73.21
Hoopeston Regional Hlth Center,9100154,FILTER SMOKE NEPTUNE ULPA,231768,,272,"$1,816.88 ","$1,816.88 ",$508.73 ,"$1,662.45 ","$1,271.82 ","$1,520.73 ","$1,662.45 ","$1,662.45 ","$1,662.45 ",$669.52 ,"$1,090.13 ",$545.06 ,"$1,635.19 ","$1,362.66 ","$1,453.50 ","$1,508.01 "
Hoopeston Regional Hlth Center,9100154,MANIFOLD NEPTUNE 4PORT,232005,,272,$70.88 ,$70.88 ,$19.85 ,$64.86 ,$49.62 ,$59.33 ,$64.86 ,$64.86 ,$64.86 ,$26.12 ,$42.53 ,$21.26 ,$63.79 ,$53.16 ,$56.70 ,$58.83
Hoopeston Regional Hlth Center,9100154,FILTER PUREVIEW 10/BX,235158,,272,$96.75 ,$96.75 ,$27.09 ,$88.53 ,$67.73 ,$80.98 ,$88.53 ,$88.53 ,$88.53 ,$35.65 ,$58.05 ,$29.03 ,$87.08 ,$72.56 ,$77.40 ,$80.30
Hoopeston Regional Hlth Center,9100154,CATH SAFETY IV 18GA 1.25IN,238,,272,$6.75 ,$6.75 ,$1.89 ,$6.18 ,$4.73 ,$5.65 ,$6.18 ,$6.18 ,$6.18 ,$2.49 ,$4.05 ,$2.03 ,$6.08 ,$5.06 ,$5.40 ,$5.60
Hoopeston Regional Hlth Center,9100154,CATH SAFETY IV 20GA 1.25IN,239,,272,$6.75 ,$6.75 ,$1.89 ,$6.18 ,$4.73 ,$5.65 ,$6.18 ,$6.18 ,$6.18 ,$2.49 ,$4.05 ,$2.03 ,$6.08 ,$5.06 ,$5.40 ,$5.60
Hoopeston Regional Hlth Center,9100154,CATH SAFETY IV 24GA X 5/8IN WINGE,241,,272,$6.75 ,$6.75 ,$1.89 ,$6.18 ,$4.73 ,$5.65 ,$6.18 ,$6.18 ,$6.18 ,$2.49 ,$4.05 ,$2.03 ,$6.08 ,$5.06 ,$5.40 ,$5.60
Hoopeston Regional Hlth Center,9100154,COUNTER NEEDLE MAGNET BOX,242,,272,$2.99 ,$2.99 ,$0.84 ,$2.74 ,$2.09 ,$2.50 ,$2.74 ,$2.74 ,$2.74 ,$1.10 ,$1.79 ,$0.90 ,$2.69 ,$2.24 ,$2.39 ,$2.48
Hoopeston Regional Hlth Center,9100154,NEEDLE HYPO 19G X 1IN 100/BX,244,,272,$0.12 ,$0.12 ,$0.03 ,$0.11 ,$0.08 ,$0.10 ,$0.11 ,$0.11 ,$0.11 ,$0.04 ,$0.07 ,$0.04 ,$0.11 ,$0.09 ,$0.10 ,$0.10
Hoopeston Regional Hlth Center,9100154,NEEDLE SAFETY 23GA X 1IN SAFETYGL,247,,272,$0.92 ,$0.92 ,$0.26 ,$0.84 ,$0.64 ,$0.77 ,$0.84 ,$0.84 ,$0.84 ,$0.34 ,$0.55 ,$0.28 ,$0.83 ,$0.69 ,$0.74 ,$0.76
Hoopeston Regional Hlth Center,9100154,NEEDLE BLUNT FILL 100/BX,251,,272,$0.30 ,$0.30 ,$0.08 ,$0.27 ,$0.21 ,$0.25 ,$0.27 ,$0.27 ,$0.27 ,$0.11 ,$0.18 ,$0.09 ,$0.27 ,$0.23 ,$0.24 ,$0.25
Hoopeston Regional Hlth Center,9100154,BLADE CERVICAL BIOPSY,2566,,272,$85.40 ,$85.40 ,$23.91 ,$78.14 ,$59.78 ,$71.48 ,$78.14 ,$78.14 ,$78.14 ,$31.47 ,$51.24 ,$25.62 ,$76.86 ,$64.05 ,$68.32 ,$70.88
Hoopeston Regional Hlth Center,9100154,PACK BASIC,269,,272,$27.07 ,$27.07 ,$7.58 ,$24.77 ,$18.95 ,$22.66 ,$24.77 ,$24.77 ,$24.77 ,$9.98 ,$16.24 ,$8.12 ,$24.36 ,$20.30 ,$21.66 ,$22.47
Hoopeston Regional Hlth Center,9100154,PACK CYSTOSCOPY CUSTOM 3/CA,274,,272,$123.35 ,$123.35 ,$34.54 ,$112.87 ,$86.35 ,$103.24 ,$112.87 ,$112.87 ,$112.87 ,$45.45 ,$74.01 ,$37.01 ,$111.02 ,$92.51 ,$98.68 ,$102.38
Hoopeston Regional Hlth Center,9100154,PACK EXTREMITY,276,,272,$57.04 ,$57.04 ,$15.97 ,$52.19 ,$39.93 ,$47.74 ,$52.19 ,$52.19 ,$52.19 ,$21.02 ,$34.22 ,$17.11 ,$51.34 ,$42.78 ,$45.63 ,$47.34
Hoopeston Regional Hlth Center,9100154,PACK LAPAROTOMY,284,,272,$54.68 ,$54.68 ,$15.31 ,$50.03 ,$38.28 ,$45.77 ,$50.03 ,$50.03 ,$50.03 ,$20.15 ,$32.81 ,$16.40 ,$49.21 ,$41.01 ,$43.74 ,$45.38
Hoopeston Regional Hlth Center,9100154,PACK MAIN OR NECK CUSTOM,286,,272,$254.48 ,$254.48 ,$71.25 ,$232.85 ,$178.14 ,$213.00 ,$232.85 ,$232.85 ,$232.85 ,$93.78 ,$152.69 ,$76.34 ,$229.03 ,$190.86 ,$203.58 ,$211.22
Hoopeston Regional Hlth Center,9100154,PACK LAP CHOLE CUSTOM,292,,272,$187.43 ,$187.43 ,$52.48 ,$171.50 ,$131.20 ,$156.88 ,$171.50 ,$171.50 ,$171.50 ,$69.07 ,$112.46 ,$56.23 ,$168.69 ,$140.57 ,$149.94 ,$155.57
Hoopeston Regional Hlth Center,9100154,PACK LITHOTOMY PERI/GYN,296,,272,$27.42 ,$27.42 ,$7.68 ,$25.09 ,$19.19 ,$22.95 ,$25.09 ,$25.09 ,$25.09 ,$10.10 ,$16.45 ,$8.23 ,$24.68 ,$20.57 ,$21.94 ,$22.76
Hoopeston Regional Hlth Center,9100154,PACK MAIN OR GENERAL CUSTOM,297,,272,$229.55 ,$229.55 ,$64.27 ,$210.04 ,$160.69 ,$192.13 ,$210.04 ,$210.04 ,$210.04 ,$84.59 ,$137.73 ,$68.87 ,$206.60 ,$172.16 ,$183.64 ,$190.53
Hoopeston Regional Hlth Center,9100154,STRIP PACKING IODOFORM 0.5IN,305,,272,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9100154,STRIP PACKING IODOFORM 0.25IN,306,,272,$6.68 ,$6.68 ,$1.87 ,$6.11 ,$4.68 ,$5.59 ,$6.11 ,$6.11 ,$6.11 ,$2.46 ,$4.01 ,$2.00 ,$6.01 ,$5.01 ,$5.34 ,$5.54
Hoopeston Regional Hlth Center,9100154,STRIP PACKING IODOFORM 1IN,307,,272,$8.25 ,$8.25 ,$2.31 ,$7.55 ,$5.78 ,$6.91 ,$7.55 ,$7.55 ,$7.55 ,$3.04 ,$4.95 ,$2.48 ,$7.43 ,$6.19 ,$6.60 ,$6.85
Hoopeston Regional Hlth Center,9100154,STRIP PACKING PLAIN 0.5IN,308,,272,$6.38 ,$6.38 ,$1.79 ,$5.84 ,$4.47 ,$5.34 ,$5.84 ,$5.84 ,$5.84 ,$2.35 ,$3.83 ,$1.91 ,$5.74 ,$4.79 ,$5.10 ,$5.30
Hoopeston Regional Hlth Center,9100154,STRIP PACKING PLAIN 1IN,309,,272,$7.25 ,$7.25 ,$2.03 ,$6.63 ,$5.08 ,$6.07 ,$6.63 ,$6.63 ,$6.63 ,$2.67 ,$4.35 ,$2.18 ,$6.53 ,$5.44 ,$5.80 ,$6.02
Hoopeston Regional Hlth Center,9100154,PAD EYE OVAL,312,,272,$0.35 ,$0.35 ,$0.10 ,$0.32 ,$0.25 ,$0.29 ,$0.32 ,$0.32 ,$0.32 ,$0.13 ,$0.21 ,$0.11 ,$0.32 ,$0.26 ,$0.28 ,$0.29
Hoopeston Regional Hlth Center,9100154,PAD PREPPING PROXIMA 100/CA,313,,272,$3.59 ,$3.59 ,$1.01 ,$3.28 ,$2.51 ,$3.00 ,$3.28 ,$3.28 ,$3.28 ,$1.32 ,$2.15 ,$1.08 ,$3.23 ,$2.69 ,$2.87 ,$2.98
Hoopeston Regional Hlth Center,9100154,PITCHER STERILE PLASTIC,315,,272,$5.42 ,$5.42 ,$1.52 ,$4.96 ,$3.79 ,$4.54 ,$4.96 ,$4.96 ,$4.96 ,$2.00 ,$3.25 ,$1.63 ,$4.88 ,$4.07 ,$4.34 ,$4.50
Hoopeston Regional Hlth Center,9100154,APPLICATOR CHLORAPREP ORG 26ML W/,316,,272,$27.50 ,$27.50 ,$7.70 ,$25.16 ,$19.25 ,$23.02 ,$25.16 ,$25.16 ,$25.16 ,$10.13 ,$16.50 ,$8.25 ,$24.75 ,$20.63 ,$22.00 ,$22.83
Hoopeston Regional Hlth Center,9100154,APPLICATOR DURAPREP,317,,272,$16.36 ,$16.36 ,$4.58 ,$14.97 ,$11.45 ,$13.69 ,$14.97 ,$14.97 ,$14.97 ,$6.03 ,$9.82 ,$4.91 ,$14.72 ,$12.27 ,$13.09 ,$13.58
Hoopeston Regional Hlth Center,9100154,APPLICATOR CHLORAPREP ONESTEP 3ML,318,,272,$3.70 ,$3.70 ,$1.04 ,$3.39 ,$2.59 ,$3.10 ,$3.39 ,$3.39 ,$3.39 ,$1.36 ,$2.22 ,$1.11 ,$3.33 ,$2.78 ,$2.96 ,$3.07
Hoopeston Regional Hlth Center,9100154,PROTECTOR HEEL/ELBOW HEELBOW NOT,319,,272,$9.45 ,$9.45 ,$2.65 ,$8.65 ,$6.62 ,$7.91 ,$8.65 ,$8.65 ,$8.65 ,$3.48 ,$5.67 ,$2.84 ,$8.51 ,$7.09 ,$7.56 ,$7.84
Hoopeston Regional Hlth Center,9100154,SET BLOOD Y TYPE PLUM,340,,272,$10.50 ,$10.50 ,$2.94 ,$9.61 ,$7.35 ,$8.79 ,$9.61 ,$9.61 ,$9.61 ,$3.87 ,$6.30 ,$3.15 ,$9.45 ,$7.88 ,$8.40 ,$8.72
Hoopeston Regional Hlth Center,9100154,SET TUR Y,345,,272,$31.13 ,$31.13 ,$8.72 ,$28.48 ,$21.79 ,$26.06 ,$28.48 ,$28.48 ,$28.48 ,$11.47 ,$18.68 ,$9.34 ,$28.02 ,$23.35 ,$24.90 ,$25.84
Hoopeston Regional Hlth Center,9100154,SET PRIMARY IV PLUM,346,,272,$18.72 ,$18.72 ,$5.24 ,$17.13 ,$13.10 ,$15.67 ,$17.13 ,$17.13 ,$17.13 ,$6.90 ,$11.23 ,$5.62 ,$16.85 ,$14.04 ,$14.98 ,$15.54
Hoopeston Regional Hlth Center,9100154,SOLUTION STRL IRR BSS 500ML use #,347,,272,$23.63 ,$23.63 ,$6.62 ,$21.62 ,$16.54 ,$19.78 ,$21.62 ,$21.62 ,$21.62 ,$8.71 ,$14.18 ,$7.09 ,$21.27 ,$17.72 ,$18.90 ,$19.61
Hoopeston Regional Hlth Center,9100154,DRAPE LAPAROTOMY 77X122IN,348,,272,$18.65 ,$18.65 ,$5.22 ,$17.06 ,$13.06 ,$15.61 ,$17.06 ,$17.06 ,$17.06 ,$6.87 ,$11.19 ,$5.60 ,$16.79 ,$13.99 ,$14.92 ,$15.48
Hoopeston Regional Hlth Center,9100154,APPLICATOR COTTON TIP 3IN,36,,272,$2.20 ,$2.20 ,$0.62 ,$2.01 ,$1.54 ,$1.84 ,$2.01 ,$2.01 ,$2.01 ,$0.81 ,$1.32 ,$0.66 ,$1.98 ,$1.65 ,$1.76 ,$1.83
Hoopeston Regional Hlth Center,9100154,SOL IRR .9 NACL 1000ML 12/CASE,363,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL IRR .9 NACL 3000ML 4/CASE,364,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL .9 NACL 1000ML 12/CASE,366,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL .9 NACL GRIFOLS 250ML GRIFOLS,367,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL .9 NACL 50ML 48/CASE,368,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL .9 NACL 500ML 24/CASE,369,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,APPLICATOR COTTON TIP 6IN 100 EA/,37,,272,$0.22 ,$0.22 ,$0.06 ,$0.20 ,$0.15 ,$0.18 ,$0.20 ,$0.20 ,$0.20 ,$0.08 ,$0.13 ,$0.07 ,$0.20 ,$0.17 ,$0.18 ,$0.18
Hoopeston Regional Hlth Center,9100154,SOL D10 1000ML 12/CASE,371,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 LR 1000ML 12/CASE,372,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 .9 NACL 1000ML 12/CASE,373,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL .9 NACL 40KCL 1000ML 12/CASE,375,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 1000ML 12/CASE,377,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 250ML 24/CASE,379,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,LEGGING ATHROMBIC REGULAR,38,,272,$45.18 ,$45.18 ,$12.65 ,$41.34 ,$31.63 ,$37.82 ,$41.34 ,$41.34 ,$41.34 ,$16.65 ,$27.11 ,$13.55 ,$40.66 ,$33.89 ,$36.14 ,$37.50
Hoopeston Regional Hlth Center,9100154,SOL D5 50ML VIS IV - 60/CASE,380,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 .9 NACL 20KCL 1000ML 12/CA,381,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 .9 NACL 40KCL 1000ML 12/CA,382,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL .9 NACL 20KCL 1000ML 12/CASE,383,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 500ML 24/CASE,384,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 .45 NACL 1000ML 12/CASE,385,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 .45 NACL 30KCL 1000ML 12/C,386,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 .45 NACL 40KCL 1000ML 12/C,387,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 .45 NACL 10KCL 1000ML 12/C,388,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 .45 NACL 20KCL 1000ML 12/C,389,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,LEGGING ATHROMBIC LARGE CALF,39,,272,$70.31 ,$70.31 ,$19.69 ,$64.33 ,$49.22 ,$58.85 ,$64.33 ,$64.33 ,$64.33 ,$25.91 ,$42.19 ,$21.09 ,$63.28 ,$52.73 ,$56.25 ,$58.36
Hoopeston Regional Hlth Center,9100154,SOL D5 .225 NACL 1000ML 12/CASE,390,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL IRR GLYCINE 1.5 3000ML 4/CASE,393,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL D5 LR 20KCL 1000ML 12/CASE,395,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL LR 1000ML 12/CASE,396,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL IRR WATER 1000ML 12/CASE,400,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL .45 NACL 1000ML 12/CASE,401,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,STICK SPONGE POVIDONE-IODINE PAIN,410,,272,$13.85 ,$13.85 ,$3.88 ,$12.67 ,$9.70 ,$11.59 ,$12.67 ,$12.67 ,$12.67 ,$5.10 ,$8.31 ,$4.16 ,$12.47 ,$10.39 ,$11.08 ,$11.50
Hoopeston Regional Hlth Center,9100154,SPONGE GAUZE 4 X 4 TRAY 8-PLY,411,,272,$1.63 ,$1.63 ,$0.46 ,$1.49 ,$1.14 ,$1.36 ,$1.49 ,$1.49 ,$1.49 ,$0.60 ,$0.98 ,$0.49 ,$1.47 ,$1.22 ,$1.30 ,$1.35
Hoopeston Regional Hlth Center,9100154,SPONGE KITTNER,413,,272,$2.37 ,$2.37 ,$0.66 ,$2.17 ,$1.66 ,$1.98 ,$2.17 ,$2.17 ,$2.17 ,$0.87 ,$1.42 ,$0.71 ,$2.13 ,$1.78 ,$1.90 ,$1.97
Hoopeston Regional Hlth Center,9100154,SPONGE KERLIX FLUFF 6 X 6,414,,272,$2.04 ,$2.04 ,$0.57 ,$1.87 ,$1.43 ,$1.71 ,$1.87 ,$1.87 ,$1.87 ,$0.75 ,$1.22 ,$0.61 ,$1.84 ,$1.53 ,$1.63 ,$1.69
Hoopeston Regional Hlth Center,9100154,SPONGE LAP 18 X 18,415,,272,$5.93 ,$5.93 ,$1.66 ,$5.43 ,$4.15 ,$4.96 ,$5.43 ,$5.43 ,$5.43 ,$2.19 ,$3.56 ,$1.78 ,$5.34 ,$4.45 ,$4.74 ,$4.92
Hoopeston Regional Hlth Center,9100154,SPONGE LAP 18 X 4,416,,272,$3.65 ,$3.65 ,$1.02 ,$3.34 ,$2.56 ,$3.06 ,$3.34 ,$3.34 ,$3.34 ,$1.35 ,$2.19 ,$1.10 ,$3.29 ,$2.74 ,$2.92 ,$3.03
Hoopeston Regional Hlth Center,9100154,SPONGE RAY-TEC 4 X 4 10 TRAY,417,,272,$2.18 ,$2.18 ,$0.61 ,$1.99 ,$1.53 ,$1.82 ,$1.99 ,$1.99 ,$1.99 ,$0.80 ,$1.31 ,$0.65 ,$1.96 ,$1.64 ,$1.74 ,$1.81
Hoopeston Regional Hlth Center,9100154,STERISTRIP 0.5 X 4IN,422,,272,$3.47 ,$3.47 ,$0.97 ,$3.18 ,$2.43 ,$2.90 ,$3.18 ,$3.18 ,$3.18 ,$1.28 ,$2.08 ,$1.04 ,$3.12 ,$2.60 ,$2.78 ,$2.88
Hoopeston Regional Hlth Center,9100154,STERISTRIP 0.25IN X 4IN,423,,272,$3.47 ,$3.47 ,$0.97 ,$3.18 ,$2.43 ,$2.90 ,$3.18 ,$3.18 ,$3.18 ,$1.28 ,$2.08 ,$1.04 ,$3.12 ,$2.60 ,$2.78 ,$2.88
Hoopeston Regional Hlth Center,9100154,STOCKING COMPR KNEE LARGE REG,426,,272,$7.90 ,$7.90 ,$2.21 ,$7.23 ,$5.53 ,$6.61 ,$7.23 ,$7.23 ,$7.23 ,$2.91 ,$4.74 ,$2.37 ,$7.11 ,$5.93 ,$6.32 ,$6.56
Hoopeston Regional Hlth Center,9100154,STOCKING COMPR THIGH LARGE REG,427,,272,$15.80 ,$15.80 ,$4.42 ,$14.46 ,$11.06 ,$13.22 ,$14.46 ,$14.46 ,$14.46 ,$5.82 ,$9.48 ,$4.74 ,$14.22 ,$11.85 ,$12.64 ,$13.11
Hoopeston Regional Hlth Center,9100154,STOCKING COMPR THIGH MED REG,429,,272,$15.80 ,$15.80 ,$4.42 ,$14.46 ,$11.06 ,$13.22 ,$14.46 ,$14.46 ,$14.46 ,$5.82 ,$9.48 ,$4.74 ,$14.22 ,$11.85 ,$12.64 ,$13.11
Hoopeston Regional Hlth Center,9100154,STOCKING COMPR KNEE MED REG,430,,272,$7.90 ,$7.90 ,$2.21 ,$7.23 ,$5.53 ,$6.61 ,$7.23 ,$7.23 ,$7.23 ,$2.91 ,$4.74 ,$2.37 ,$7.11 ,$5.93 ,$6.32 ,$6.56
Hoopeston Regional Hlth Center,9100154,STOCKING COMPR KNEE SMALL REG,431,,272,$7.90 ,$7.90 ,$2.21 ,$7.23 ,$5.53 ,$6.61 ,$7.23 ,$7.23 ,$7.23 ,$2.91 ,$4.74 ,$2.37 ,$7.11 ,$5.93 ,$6.32 ,$6.56
Hoopeston Regional Hlth Center,9100154,STOCKING COMPR THIGH XL REG,432,,272,$15.80 ,$15.80 ,$4.42 ,$14.46 ,$11.06 ,$13.22 ,$14.46 ,$14.46 ,$14.46 ,$5.82 ,$9.48 ,$4.74 ,$14.22 ,$11.85 ,$12.64 ,$13.11
Hoopeston Regional Hlth Center,9100154,NEEDLE INSUFFLATION 120MM BX/10,43294,,272,$99.65 ,$99.65 ,$27.90 ,$91.18 ,$69.76 ,$83.41 ,$91.18 ,$91.18 ,$91.18 ,$36.72 ,$59.79 ,$29.90 ,$89.69 ,$74.74 ,$79.72 ,$82.71
Hoopeston Regional Hlth Center,9100154,PAD ABDOMINAL SURGIPAD 8X7-1/2 ST,440,,272,$0.58 ,$0.58 ,$0.16 ,$0.53 ,$0.41 ,$0.49 ,$0.53 ,$0.53 ,$0.53 ,$0.21 ,$0.35 ,$0.17 ,$0.52 ,$0.44 ,$0.46 ,$0.48
Hoopeston Regional Hlth Center,9100154,SUPPORT ATHLETIC XLARGE,442,,272,$14.45 ,$14.45 ,$4.05 ,$13.22 ,$10.12 ,$12.09 ,$13.22 ,$13.22 ,$13.22 ,$5.32 ,$8.67 ,$4.34 ,$13.01 ,$10.84 ,$11.56 ,$11.99
Hoopeston Regional Hlth Center,9100154,STAPLER SKIN 35 WIDE 6/BX,444,,272,$33.27 ,$33.27 ,$9.32 ,$30.44 ,$23.29 ,$27.85 ,$30.44 ,$30.44 ,$30.44 ,$12.26 ,$19.96 ,$9.98 ,$29.94 ,$24.95 ,$26.62 ,$27.61
Hoopeston Regional Hlth Center,9100154,SWAB GYNE 8IN 50/BX,449,,272,$1.04 ,$1.04 ,$0.29 ,$0.95 ,$0.73 ,$0.87 ,$0.95 ,$0.95 ,$0.95 ,$0.38 ,$0.62 ,$0.31 ,$0.94 ,$0.78 ,$0.83 ,$0.86
Hoopeston Regional Hlth Center,9100154,SWABSTICK POVIDONE IODINE 3/PK,450,,272,$1.07 ,$1.07 ,$0.30 ,$0.98 ,$0.75 ,$0.90 ,$0.98 ,$0.98 ,$0.98 ,$0.39 ,$0.64 ,$0.32 ,$0.96 ,$0.80 ,$0.86 ,$0.89
Hoopeston Regional Hlth Center,9100154,SYRINGE BULB IRRIGATION 60CC,453,,272,$2.80 ,$2.80 ,$0.78 ,$2.56 ,$1.96 ,$2.34 ,$2.56 ,$2.56 ,$2.56 ,$1.03 ,$1.68 ,$0.84 ,$2.52 ,$2.10 ,$2.24 ,$2.32
Hoopeston Regional Hlth Center,9100154,SYRINGE 3ML LL,454,,272,$0.18 ,$0.18 ,$0.05 ,$0.16 ,$0.13 ,$0.15 ,$0.16 ,$0.16 ,$0.16 ,$0.07 ,$0.11 ,$0.05 ,$0.16 ,$0.14 ,$0.14 ,$0.15
Hoopeston Regional Hlth Center,9100154,SYRINGE 5ML LL,455,,272,$0.29 ,$0.29 ,$0.08 ,$0.27 ,$0.20 ,$0.24 ,$0.27 ,$0.27 ,$0.27 ,$0.11 ,$0.17 ,$0.09 ,$0.26 ,$0.22 ,$0.23 ,$0.24
Hoopeston Regional Hlth Center,9100154,SYRINGE 10ML LL 200/BOX,456,,272,$0.32 ,$0.32 ,$0.09 ,$0.29 ,$0.22 ,$0.27 ,$0.29 ,$0.29 ,$0.29 ,$0.12 ,$0.19 ,$0.10 ,$0.29 ,$0.24 ,$0.26 ,$0.27
Hoopeston Regional Hlth Center,9100154,SYRINGE 20ML LL 48/BX,457,,272,$0.73 ,$0.73 ,$0.20 ,$0.67 ,$0.51 ,$0.61 ,$0.67 ,$0.67 ,$0.67 ,$0.27 ,$0.44 ,$0.22 ,$0.66 ,$0.55 ,$0.58 ,$0.61
Hoopeston Regional Hlth Center,9100154,SYRINGE SAFETY 3CC 22G X 1.5IN EC,458,,272,$0.85 ,$0.85 ,$0.24 ,$0.78 ,$0.60 ,$0.71 ,$0.78 ,$0.78 ,$0.78 ,$0.31 ,$0.51 ,$0.26 ,$0.77 ,$0.64 ,$0.68 ,$0.71
Hoopeston Regional Hlth Center,9100154,SYRINGE 1ML LEUR LOK 100/BX,460,,272,$1.02 ,$1.02 ,$0.29 ,$0.93 ,$0.71 ,$0.85 ,$0.93 ,$0.93 ,$0.93 ,$0.38 ,$0.61 ,$0.31 ,$0.92 ,$0.77 ,$0.82 ,$0.85
Hoopeston Regional Hlth Center,9100154,SYRINGE 50ML LL 40/BX,462,,272,$1.32 ,$1.32 ,$0.37 ,$1.21 ,$0.92 ,$1.10 ,$1.21 ,$1.21 ,$1.21 ,$0.49 ,$0.79 ,$0.40 ,$1.19 ,$0.99 ,$1.06 ,$1.10
Hoopeston Regional Hlth Center,9100154,SYRINGE CATHETER TIP 50ML,463,,272,$1.29 ,$1.29 ,$0.36 ,$1.18 ,$0.90 ,$1.08 ,$1.18 ,$1.18 ,$1.18 ,$0.48 ,$0.77 ,$0.39 ,$1.16 ,$0.97 ,$1.03 ,$1.07
Hoopeston Regional Hlth Center,9100154,TAPE PAPER MICROPORE 2IN,471,,272,$2.44 ,$2.44 ,$0.68 ,$2.23 ,$1.71 ,$2.04 ,$2.23 ,$2.23 ,$2.23 ,$0.90 ,$1.46 ,$0.73 ,$2.20 ,$1.83 ,$1.95 ,$2.03
Hoopeston Regional Hlth Center,9100154,YANKAUER TUBE K80 TAPERED BULBOUS,479,,272,$1.30 ,$1.30 ,$0.36 ,$1.19 ,$0.91 ,$1.09 ,$1.19 ,$1.19 ,$1.19 ,$0.48 ,$0.78 ,$0.39 ,$1.17 ,$0.98 ,$1.04 ,$1.08
Hoopeston Regional Hlth Center,9100154,TOWEL WHITE SURGICAL 16X26 4PK,481,,272,$8.52 ,$8.52 ,$2.39 ,$7.80 ,$5.96 ,$7.13 ,$7.80 ,$7.80 ,$7.80 ,$3.14 ,$5.11 ,$2.56 ,$7.67 ,$6.39 ,$6.82 ,$7.07
Hoopeston Regional Hlth Center,9100154,TRAY CATH URINE METER 16FR10CC SI,485,,272,$58.80 ,$58.80 ,$16.46 ,$53.80 ,$41.16 ,$49.22 ,$53.80 ,$53.80 ,$53.80 ,$21.67 ,$35.28 ,$17.64 ,$52.92 ,$44.10 ,$47.04 ,$48.80
Hoopeston Regional Hlth Center,9100154,TRAY IRRIGATION W/PISTON,490,,272,$5.20 ,$5.20 ,$1.46 ,$4.76 ,$3.64 ,$4.35 ,$4.76 ,$4.76 ,$4.76 ,$1.92 ,$3.12 ,$1.56 ,$4.68 ,$3.90 ,$4.16 ,$4.32
Hoopeston Regional Hlth Center,9100154,SYSTEM PARA/THORACENTESIS DRAIN,494,,272,$233.63 ,$233.63 ,$65.42 ,$213.77 ,$163.54 ,$195.55 ,$213.77 ,$213.77 ,$213.77 ,$86.09 ,$140.18 ,$70.09 ,$210.27 ,$175.22 ,$186.90 ,$193.91
Hoopeston Regional Hlth Center,9100154,SET TUBING IV EXTENSION 30IN MACR,498,,272,$3.18 ,$3.18 ,$0.89 ,$2.91 ,$2.23 ,$2.66 ,$2.91 ,$2.91 ,$2.91 ,$1.17 ,$1.91 ,$0.95 ,$2.86 ,$2.39 ,$2.54 ,$2.64
Hoopeston Regional Hlth Center,9100154,TUBE FEEDING 8FR 16IN,500,,272,$2.60 ,$2.60 ,$0.73 ,$2.38 ,$1.82 ,$2.18 ,$2.38 ,$2.38 ,$2.38 ,$0.96 ,$1.56 ,$0.78 ,$2.34 ,$1.95 ,$2.08 ,$2.16
Hoopeston Regional Hlth Center,9100154,DRAIN PENROSE .5IN 18IN LATEX,505,,272,$1.49 ,$1.49 ,$0.42 ,$1.36 ,$1.04 ,$1.25 ,$1.36 ,$1.36 ,$1.36 ,$0.55 ,$0.89 ,$0.45 ,$1.34 ,$1.12 ,$1.19 ,$1.24
Hoopeston Regional Hlth Center,9100154,DRAIN PENROSE .25IN 18IN LATEX,506,,272,$3.70 ,$3.70 ,$1.04 ,$3.39 ,$2.59 ,$3.10 ,$3.39 ,$3.39 ,$3.39 ,$1.36 ,$2.22 ,$1.11 ,$3.33 ,$2.78 ,$2.96 ,$3.07
Hoopeston Regional Hlth Center,9100154,TUBE NG SALEM 12FR 10/CA,507,,272,$5.04 ,$5.04 ,$1.41 ,$4.61 ,$3.53 ,$4.22 ,$4.61 ,$4.61 ,$4.61 ,$1.86 ,$3.02 ,$1.51 ,$4.54 ,$3.78 ,$4.03 ,$4.18
Hoopeston Regional Hlth Center,9100154,TUBE NG SALEM 16FR 10/CA,508,,272,$5.04 ,$5.04 ,$1.41 ,$4.61 ,$3.53 ,$4.22 ,$4.61 ,$4.61 ,$4.61 ,$1.86 ,$3.02 ,$1.51 ,$4.54 ,$3.78 ,$4.03 ,$4.18
Hoopeston Regional Hlth Center,9100154,TUBE NG SALEM 18FR 10/CA,509,,272,$5.04 ,$5.04 ,$1.41 ,$4.61 ,$3.53 ,$4.22 ,$4.61 ,$4.61 ,$4.61 ,$1.86 ,$3.02 ,$1.51 ,$4.54 ,$3.78 ,$4.03 ,$4.18
Hoopeston Regional Hlth Center,9100154,TUBING SUCTION 9/32INX20FT,510,,272,$6.44 ,$6.44 ,$1.80 ,$5.89 ,$4.51 ,$5.39 ,$5.89 ,$5.89 ,$5.89 ,$2.37 ,$3.86 ,$1.93 ,$5.80 ,$4.83 ,$5.15 ,$5.35
Hoopeston Regional Hlth Center,9100154,BANDAGE ACE 3IN NS VELCRO,52,,272,$1.66 ,$1.66 ,$0.46 ,$1.52 ,$1.16 ,$1.39 ,$1.52 ,$1.52 ,$1.52 ,$0.61 ,$1.00 ,$0.50 ,$1.49 ,$1.25 ,$1.33 ,$1.38
Hoopeston Regional Hlth Center,9100154,TRAY CATH URINE METER 16FR 5CC US,522,,272,$89.54 ,$89.54 ,$25.07 ,$81.93 ,$62.68 ,$74.94 ,$81.93 ,$81.93 ,$81.93 ,$33.00 ,$53.72 ,$26.86 ,$80.59 ,$67.16 ,$71.63 ,$74.32
Hoopeston Regional Hlth Center,9100154,PASSER SUTURE EASE BX/5,52601,,272,$382.50 ,$382.50 ,$107.10 ,$349.99 ,$267.75 ,$320.15 ,$349.99 ,$349.99 ,$349.99 ,$140.95 ,$229.50 ,$114.75 ,$344.25 ,$286.88 ,$306.00 ,$317.48
Hoopeston Regional Hlth Center,9100154,TUBING ENDOGATOR IRRIGATION Use #,532,,272,$60.57 ,$60.57 ,$16.96 ,$55.42 ,$42.40 ,$50.70 ,$55.42 ,$55.42 ,$55.42 ,$22.32 ,$36.34 ,$18.17 ,$54.51 ,$45.43 ,$48.46 ,$50.27
Hoopeston Regional Hlth Center,9100154,BANDAGE ACE 6IN NS VELCRO,54,,272,$3.16 ,$3.16 ,$0.88 ,$2.89 ,$2.21 ,$2.64 ,$2.89 ,$2.89 ,$2.89 ,$1.16 ,$1.90 ,$0.95 ,$2.84 ,$2.37 ,$2.53 ,$2.62
Hoopeston Regional Hlth Center,9100154,SOL ANTIFOG,544,,272,$6.92 ,$6.92 ,$1.94 ,$6.33 ,$4.84 ,$5.79 ,$6.33 ,$6.33 ,$6.33 ,$2.55 ,$4.15 ,$2.08 ,$6.23 ,$5.19 ,$5.54 ,$5.74
Hoopeston Regional Hlth Center,9100154,ISOVUE 300 50ML 10X5 10/CA,54641,,272,$18.02 ,$18.02 ,$5.05 ,$16.49 ,$12.61 ,$15.08 ,$16.49 ,$16.49 ,$16.49 ,$6.64 ,$10.81 ,$5.41 ,$16.22 ,$13.52 ,$14.42 ,$14.96
Hoopeston Regional Hlth Center,9100154,BINDER ABDOM LRG 46-62IN X 9IN,56,,272,$2.86 ,$2.86 ,$0.80 ,$2.62 ,$2.00 ,$2.39 ,$2.62 ,$2.62 ,$2.62 ,$1.05 ,$1.72 ,$0.86 ,$2.57 ,$2.15 ,$2.29 ,$2.37
Hoopeston Regional Hlth Center,9100154,DECANTER BAG,560,,272,$2.93 ,$2.93 ,$0.82 ,$2.68 ,$2.05 ,$2.45 ,$2.68 ,$2.68 ,$2.68 ,$1.08 ,$1.76 ,$0.88 ,$2.64 ,$2.20 ,$2.34 ,$2.43
Hoopeston Regional Hlth Center,9100154,BLADE ONLY SCALPEL #10 DISPOSABLE,58,,272,$1.12 ,$1.12 ,$0.31 ,$1.02 ,$0.78 ,$0.94 ,$1.02 ,$1.02 ,$1.02 ,$0.41 ,$0.67 ,$0.34 ,$1.01 ,$0.84 ,$0.90 ,$0.93
Hoopeston Regional Hlth Center,9100154,BANDAGE ACE 4IN STERILE,581,,272,$3.35 ,$3.35 ,$0.94 ,$3.07 ,$2.35 ,$2.80 ,$3.07 ,$3.07 ,$3.07 ,$1.23 ,$2.01 ,$1.01 ,$3.02 ,$2.51 ,$2.68 ,$2.78
Hoopeston Regional Hlth Center,9100154,BANDAGE ACE 6IN STERILE,582,,272,$4.50 ,$4.50 ,$1.26 ,$4.12 ,$3.15 ,$3.77 ,$4.12 ,$4.12 ,$4.12 ,$1.66 ,$2.70 ,$1.35 ,$4.05 ,$3.38 ,$3.60 ,$3.74
Hoopeston Regional Hlth Center,9100154,BANDAGE ESMARK 4IN STERLE,583,,272,$18.75 ,$18.75 ,$5.25 ,$17.16 ,$13.13 ,$15.69 ,$17.16 ,$17.16 ,$17.16 ,$6.91 ,$11.25 ,$5.63 ,$16.88 ,$14.06 ,$15.00 ,$15.56
Hoopeston Regional Hlth Center,9100154,BLADE ONLY SCALPEL #11 DISPOSABLE,59,,272,$1.12 ,$1.12 ,$0.31 ,$1.02 ,$0.78 ,$0.94 ,$1.02 ,$1.02 ,$1.02 ,$0.41 ,$0.67 ,$0.34 ,$1.01 ,$0.84 ,$0.90 ,$0.93
Hoopeston Regional Hlth Center,9100154,SWAB BENZOIN TINCTURE use #223725,593,,272,$2.77 ,$2.77 ,$0.78 ,$2.53 ,$1.94 ,$2.32 ,$2.53 ,$2.53 ,$2.53 ,$1.02 ,$1.66 ,$0.83 ,$2.49 ,$2.08 ,$2.22 ,$2.30
Hoopeston Regional Hlth Center,9100154,DEVICE CORE BIOPSY 18G 20MM 5 PER,595,,272,$209.40 ,$209.40 ,$58.63 ,$191.60 ,$146.58 ,$175.27 ,$191.60 ,$191.60 ,$191.60 ,$77.16 ,$125.64 ,$62.82 ,$188.46 ,$157.05 ,$167.52 ,$173.80
Hoopeston Regional Hlth Center,9100154,BLADE ONLY SCALPEL #15 DISPOSABLE,60,,272,$1.12 ,$1.12 ,$0.31 ,$1.02 ,$0.78 ,$0.94 ,$1.02 ,$1.02 ,$1.02 ,$0.41 ,$0.67 ,$0.34 ,$1.01 ,$0.84 ,$0.90 ,$0.93
Hoopeston Regional Hlth Center,9100154,KNIFE CARPAL TUNNEL,625,,272,$402.75 ,$402.75 ,$112.77 ,$368.52 ,$281.93 ,$337.10 ,$368.52 ,$368.52 ,$368.52 ,$148.41 ,$241.65 ,$120.83 ,$362.48 ,$302.06 ,$322.20 ,$334.28
Hoopeston Regional Hlth Center,9100154,BLADE SAG MICRO SAW 25X9 .024,629,,272,$28.35 ,$28.35 ,$7.94 ,$25.94 ,$19.85 ,$23.73 ,$25.94 ,$25.94 ,$25.94 ,$10.45 ,$17.01 ,$8.51 ,$25.52 ,$21.26 ,$22.68 ,$23.53
Hoopeston Regional Hlth Center,8980272,"water for injection, sterile injection solution",63323018520,,272,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 VICRYL PS-2 18IN UNDYE,64271,,272,$15.45 ,$15.45 ,$4.33 ,$14.14 ,$10.82 ,$12.93 ,$14.14 ,$14.14 ,$14.14 ,$5.69 ,$9.27 ,$4.64 ,$13.91 ,$11.59 ,$12.36 ,$12.82
Hoopeston Regional Hlth Center,9100154,BLADE SW NRRW THK 82X12.7X1.2MM S,64272,,272,$121.50 ,$121.50 ,$34.02 ,$111.17 ,$85.05 ,$101.70 ,$111.17 ,$111.17 ,$111.17 ,$44.77 ,$72.90 ,$36.45 ,$109.35 ,$91.13 ,$97.20 ,$100.85
Hoopeston Regional Hlth Center,9100154,KIT SAFETY MIC PEG PULL 20F 2/CA,64273,,272,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9100154,BAG BLUE CATARACT,64349,,272,$0.32 ,$0.32 ,$0.09 ,$0.29 ,$0.22 ,$0.27 ,$0.29 ,$0.29 ,$0.29 ,$0.12 ,$0.19 ,$0.10 ,$0.29 ,$0.24 ,$0.26 ,$0.27
Hoopeston Regional Hlth Center,9100154,PROTECTOR CORNEAL CROUCH,64350,,272,$32.22 ,$32.22 ,$9.02 ,$29.48 ,$22.55 ,$26.97 ,$29.48 ,$29.48 ,$29.48 ,$11.87 ,$19.33 ,$9.67 ,$29.00 ,$24.17 ,$25.78 ,$26.74
Hoopeston Regional Hlth Center,9100154,MITT PREP USE#620855,64352,,272,$2.16 ,$2.16 ,$0.60 ,$1.98 ,$1.51 ,$1.81 ,$1.98 ,$1.98 ,$1.98 ,$0.80 ,$1.30 ,$0.65 ,$1.94 ,$1.62 ,$1.73 ,$1.79
Hoopeston Regional Hlth Center,9100154,DRAPE ENDOSCOPY,64353,,272,$52.11 ,$52.11 ,$14.59 ,$47.68 ,$36.48 ,$43.62 ,$47.68 ,$47.68 ,$47.68 ,$19.20 ,$31.27 ,$15.63 ,$46.90 ,$39.08 ,$41.69 ,$43.25
Hoopeston Regional Hlth Center,9100154,NEEDLE BX GUIDE PROSTRATE,64355,,272,$310.50 ,$310.50 ,$86.94 ,$284.11 ,$217.35 ,$259.89 ,$284.11 ,$284.11 ,$284.11 ,$114.42 ,$186.30 ,$93.15 ,$279.45 ,$232.88 ,$248.40 ,$257.72
Hoopeston Regional Hlth Center,9100154,MICRO SAGITTAL BLADE 5.5X18.5X,64356,,272,$37.80 ,$37.80 ,$10.58 ,$34.59 ,$26.46 ,$31.64 ,$34.59 ,$34.59 ,$34.59 ,$13.93 ,$22.68 ,$11.34 ,$34.02 ,$28.35 ,$30.24 ,$31.37
Hoopeston Regional Hlth Center,9100154,SET COMMON BILE DUCT EXPL,64357,,272,"$4,287.38 ","$4,287.38 ","$1,200.47 ","$3,922.95 ","$3,001.17 ","$3,588.54 ","$3,922.95 ","$3,922.95 ","$3,922.95 ","$1,579.90 ","$2,572.43 ","$1,286.21 ","$3,858.64 ","$3,215.54 ","$3,429.90 ","$3,558.53 "
Hoopeston Regional Hlth Center,9100154,TRAP SUCTION POLYP,64358,,272,$59.40 ,$59.40 ,$16.63 ,$54.35 ,$41.58 ,$49.72 ,$54.35 ,$54.35 ,$54.35 ,$21.89 ,$35.64 ,$17.82 ,$53.46 ,$44.55 ,$47.52 ,$49.30
Hoopeston Regional Hlth Center,9100154,SET TUBE FOR FLUID SAFE PUMP,64360,,272,$492.75 ,$492.75 ,$137.97 ,$450.87 ,$344.93 ,$412.43 ,$450.87 ,$450.87 ,$450.87 ,$181.58 ,$295.65 ,$147.83 ,$443.48 ,$369.56 ,$394.20 ,$408.98
Hoopeston Regional Hlth Center,9100154,INJECTOR OLYMPUS,64363,,272,$663.75 ,$663.75 ,$185.85 ,$607.33 ,$464.63 ,$555.56 ,$607.33 ,$607.33 ,$607.33 ,$244.59 ,$398.25 ,$199.13 ,$597.38 ,$497.81 ,$531.00 ,$550.91
Hoopeston Regional Hlth Center,9100154,TRIPORT ACCESS SYSTEM,64364,,272,"$1,831.50 ","$1,831.50 ",$512.82 ,"$1,675.82 ","$1,282.05 ","$1,532.97 ","$1,675.82 ","$1,675.82 ","$1,675.82 ",$674.91 ,"$1,098.90 ",$549.45 ,"$1,648.35 ","$1,373.63 ","$1,465.20 ","$1,520.15 "
Hoopeston Regional Hlth Center,9100154,K-WIRE 0.045 SMOOTH,64365,,272,$10.67 ,$10.67 ,$2.99 ,$9.76 ,$7.47 ,$8.93 ,$9.76 ,$9.76 ,$9.76 ,$3.93 ,$6.40 ,$3.20 ,$9.60 ,$8.00 ,$8.54 ,$8.86
Hoopeston Regional Hlth Center,9100154,K-WIRE 0.062 SMOOTH,64366,,272,$10.67 ,$10.67 ,$2.99 ,$9.76 ,$7.47 ,$8.93 ,$9.76 ,$9.76 ,$9.76 ,$3.93 ,$6.40 ,$3.20 ,$9.60 ,$8.00 ,$8.54 ,$8.86
Hoopeston Regional Hlth Center,9100154,LOOP CUTTING 0.8MM,64367,,272,$866.25 ,$866.25 ,$242.55 ,$792.62 ,$606.38 ,$725.05 ,$792.62 ,$792.62 ,$792.62 ,$319.21 ,$519.75 ,$259.88 ,$779.63 ,$649.69 ,$693.00 ,$718.99
Hoopeston Regional Hlth Center,9100154,COAGULATOR SUCTION FOOT CONTRL,64368,,272,$39.60 ,$39.60 ,$11.09 ,$36.23 ,$27.72 ,$33.15 ,$36.23 ,$36.23 ,$36.23 ,$14.59 ,$23.76 ,$11.88 ,$35.64 ,$29.70 ,$31.68 ,$32.87
Hoopeston Regional Hlth Center,9100154,TUBING LAP SMOKE EVAC,64369,,272,$162.23 ,$162.23 ,$45.42 ,$148.44 ,$113.56 ,$135.79 ,$148.44 ,$148.44 ,$148.44 ,$59.78 ,$97.34 ,$48.67 ,$146.01 ,$121.67 ,$129.78 ,$134.65
Hoopeston Regional Hlth Center,9100154,TUBING ATTACHA VAC SMOKE EVAC,64370,,272,$12.56 ,$12.56 ,$3.52 ,$11.49 ,$8.79 ,$10.51 ,$11.49 ,$11.49 ,$11.49 ,$4.63 ,$7.54 ,$3.77 ,$11.30 ,$9.42 ,$10.05 ,$10.42
Hoopeston Regional Hlth Center,9100154,KIT PATCH,64371,,272,$69.75 ,$69.75 ,$19.53 ,$63.82 ,$48.83 ,$58.38 ,$63.82 ,$63.82 ,$63.82 ,$25.70 ,$41.85 ,$20.93 ,$62.78 ,$52.31 ,$55.80 ,$57.89
Hoopeston Regional Hlth Center,9100154,CARTRIDGE CEMENT MIXING,64372,,272,"$1,723.50 ","$1,723.50 ",$482.58 ,"$1,577.00 ","$1,206.45 ","$1,442.57 ","$1,577.00 ","$1,577.00 ","$1,577.00 ",$635.11 ,"$1,034.10 ",$517.05 ,"$1,551.15 ","$1,292.63 ","$1,378.80 ","$1,430.51 "
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 SILK FS2 683G,64373,,272,$6.25 ,$6.25 ,$1.75 ,$5.72 ,$4.38 ,$5.23 ,$5.72 ,$5.72 ,$5.72 ,$2.30 ,$3.75 ,$1.88 ,$5.63 ,$4.69 ,$5.00 ,$5.19
Hoopeston Regional Hlth Center,9100154,LUBRITECT,64374,,272,$66.40 ,$66.40 ,$18.59 ,$60.76 ,$46.48 ,$55.58 ,$60.76 ,$60.76 ,$60.76 ,$24.47 ,$39.84 ,$19.92 ,$59.76 ,$49.80 ,$53.12 ,$55.11
Hoopeston Regional Hlth Center,9100003,SUTURE 1 VICRYL CT2,64375,,272,$8.10 ,$8.10 ,$2.27 ,$7.41 ,$5.67 ,$6.78 ,$7.41 ,$7.41 ,$7.41 ,$2.98 ,$4.86 ,$2.43 ,$7.29 ,$6.08 ,$6.48 ,$6.72
Hoopeston Regional Hlth Center,9100154,TIP CAUTERY STUBBY,64376,,272,$24.42 ,$24.42 ,$6.84 ,$22.34 ,$17.09 ,$20.44 ,$22.34 ,$22.34 ,$22.34 ,$9.00 ,$14.65 ,$7.33 ,$21.98 ,$18.32 ,$19.54 ,$20.27
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 VICRYL CT,64377,,272,$7.14 ,$7.14 ,$2.00 ,$6.53 ,$5.00 ,$5.98 ,$6.53 ,$6.53 ,$6.53 ,$2.63 ,$4.28 ,$2.14 ,$6.43 ,$5.36 ,$5.71 ,$5.93
Hoopeston Regional Hlth Center,9100003,SUTURE 3-0 VICRYL X1,64378,,272,$10.83 ,$10.83 ,$3.03 ,$9.91 ,$7.58 ,$9.06 ,$9.91 ,$9.91 ,$9.91 ,$3.99 ,$6.50 ,$3.25 ,$9.75 ,$8.12 ,$8.66 ,$8.99
Hoopeston Regional Hlth Center,9100003,SUTURE 0 PDS CT2,64379,,272,$11.87 ,$11.87 ,$3.32 ,$10.86 ,$8.31 ,$9.94 ,$10.86 ,$10.86 ,$10.86 ,$4.37 ,$7.12 ,$3.56 ,$10.68 ,$8.90 ,$9.50 ,$9.85
Hoopeston Regional Hlth Center,9100003,SUTURE 0 VICRYL V34,64380,,272,$13.16 ,$13.16 ,$3.68 ,$12.04 ,$9.21 ,$11.01 ,$12.04 ,$12.04 ,$12.04 ,$4.85 ,$7.90 ,$3.95 ,$11.84 ,$9.87 ,$10.53 ,$10.92
Hoopeston Regional Hlth Center,9100003,SUTURE 1 ETHIBOND OS-8,64381,,272,$11.87 ,$11.87 ,$3.32 ,$10.86 ,$8.31 ,$9.94 ,$10.86 ,$10.86 ,$10.86 ,$4.37 ,$7.12 ,$3.56 ,$10.68 ,$8.90 ,$9.50 ,$9.85
Hoopeston Regional Hlth Center,9100154,STOPCOCK 3WAY 21IN EXT SET,64382,,272,$10.42 ,$10.42 ,$2.92 ,$9.53 ,$7.29 ,$8.72 ,$9.53 ,$9.53 ,$9.53 ,$3.84 ,$6.25 ,$3.13 ,$9.38 ,$7.82 ,$8.34 ,$8.65
Hoopeston Regional Hlth Center,9100003,SUTURE 4-0 SILK G3,64383,,272,$41.75 ,$41.75 ,$11.69 ,$38.20 ,$29.23 ,$34.94 ,$38.20 ,$38.20 ,$38.20 ,$15.38 ,$25.05 ,$12.53 ,$37.58 ,$31.31 ,$33.40 ,$34.65
Hoopeston Regional Hlth Center,9100154,TIP SPATULA ENDO,64384,,272,$96.08 ,$96.08 ,$26.90 ,$87.91 ,$67.26 ,$80.42 ,$87.91 ,$87.91 ,$87.91 ,$35.41 ,$57.65 ,$28.82 ,$86.47 ,$72.06 ,$76.86 ,$79.75
Hoopeston Regional Hlth Center,9100003,SUTURE 0 CHROMIC UR-6,64385,,272,$16.82 ,$16.82 ,$4.71 ,$15.39 ,$11.77 ,$14.08 ,$15.39 ,$15.39 ,$15.39 ,$6.20 ,$10.09 ,$5.05 ,$15.14 ,$12.62 ,$13.46 ,$13.96
Hoopeston Regional Hlth Center,9100003,SUTURE 1 ETHIBOND,64387,,272,$62.65 ,$62.65 ,$17.54 ,$57.32 ,$43.86 ,$52.44 ,$57.32 ,$57.32 ,$57.32 ,$23.09 ,$37.59 ,$18.80 ,$56.39 ,$46.99 ,$50.12 ,$52.00
Hoopeston Regional Hlth Center,9100154,DRAPE Z-FRICTION,64388,,272,$10.51 ,$10.51 ,$2.94 ,$9.62 ,$7.36 ,$8.80 ,$9.62 ,$9.62 ,$9.62 ,$3.87 ,$6.31 ,$3.15 ,$9.46 ,$7.88 ,$8.41 ,$8.72
Hoopeston Regional Hlth Center,9100003,SUTURE 8-0 VICRYL TG140-6,64389,,272,$87.39 ,$87.39 ,$24.47 ,$79.96 ,$61.17 ,$73.15 ,$79.96 ,$79.96 ,$79.96 ,$32.20 ,$52.43 ,$26.22 ,$78.65 ,$65.54 ,$69.91 ,$72.53
Hoopeston Regional Hlth Center,9100154,DRAIN 7 FR ROUND TLS,64390,,272,$199.46 ,$199.46 ,$55.85 ,$182.51 ,$139.62 ,$166.95 ,$182.51 ,$182.51 ,$182.51 ,$73.50 ,$119.68 ,$59.84 ,$179.51 ,$149.60 ,$159.57 ,$165.55
Hoopeston Regional Hlth Center,9100154,SNARE ELECTROSURGICAL,64391,,272,$36.45 ,$36.45 ,$10.21 ,$33.35 ,$25.52 ,$30.51 ,$33.35 ,$33.35 ,$33.35 ,$13.43 ,$21.87 ,$10.94 ,$32.81 ,$27.34 ,$29.16 ,$30.25
Hoopeston Regional Hlth Center,9100154,RETRACTOR ENDO RETRACT 2,64392,,272,"$1,376.47 ","$1,376.47 ",$385.41 ,"$1,259.47 ",$963.53 ,"$1,152.11 ","$1,259.47 ","$1,259.47 ","$1,259.47 ",$507.23 ,$825.88 ,$412.94 ,"$1,238.82 ","$1,032.35 ","$1,101.18 ","$1,142.47 "
Hoopeston Regional Hlth Center,9100003,SUTURE 5-0 PROLENE BV1,64393,,272,$87.86 ,$87.86 ,$24.60 ,$80.39 ,$61.50 ,$73.54 ,$80.39 ,$80.39 ,$80.39 ,$32.38 ,$52.72 ,$26.36 ,$79.07 ,$65.90 ,$70.29 ,$72.92
Hoopeston Regional Hlth Center,9100010,KIT ISTOP TOT RAZVI,64394,,272,"$3,127.50 ","$3,127.50 ",$875.70 ,"$2,861.66 ","$2,189.25 ","$2,617.72 ","$2,861.66 ","$2,861.66 ","$2,861.66 ","$1,152.48 ","$1,876.50 ",$938.25 ,"$2,814.75 ","$2,345.63 ","$2,502.00 ","$2,595.83 "
Hoopeston Regional Hlth Center,9100154,SET PLUM BURETTE 150ML BUETROL,64399,,272,$53.10 ,$53.10 ,$14.87 ,$48.59 ,$37.17 ,$44.44 ,$48.59 ,$48.59 ,$48.59 ,$19.57 ,$31.86 ,$15.93 ,$47.79 ,$39.83 ,$42.48 ,$44.07
Hoopeston Regional Hlth Center,9100154,BAG DRAINAGE 4L URINE,64400,,272,$11.71 ,$11.71 ,$3.28 ,$10.71 ,$8.20 ,$9.80 ,$10.71 ,$10.71 ,$10.71 ,$4.32 ,$7.03 ,$3.51 ,$10.54 ,$8.78 ,$9.37 ,$9.72
Hoopeston Regional Hlth Center,9100154,PACK DRESSING HEAVY DRAINAGE 48/C,64401,,272,$5.02 ,$5.02 ,$1.41 ,$4.59 ,$3.51 ,$4.20 ,$4.59 ,$4.59 ,$4.59 ,$1.85 ,$3.01 ,$1.51 ,$4.52 ,$3.77 ,$4.02 ,$4.17
Hoopeston Regional Hlth Center,9100154,KIT STERILE SPUTUM W/TUBE 50/CA,64402,,272,$8.67 ,$8.67 ,$2.43 ,$7.93 ,$6.07 ,$7.26 ,$7.93 ,$7.93 ,$7.93 ,$3.19 ,$5.20 ,$2.60 ,$7.80 ,$6.50 ,$6.94 ,$7.20
Hoopeston Regional Hlth Center,9100154,DRESSING VENI-GARD 500/CA,64403,,272,$2.55 ,$2.55 ,$0.71 ,$2.33 ,$1.79 ,$2.13 ,$2.33 ,$2.33 ,$2.33 ,$0.94 ,$1.53 ,$0.77 ,$2.30 ,$1.91 ,$2.04 ,$2.12
Hoopeston Regional Hlth Center,9100154,PELLETS COTTON SIZE 5 1300/BX,64408,,272,$0.05 ,$0.05 ,$0.01 ,$0.05 ,$0.04 ,$0.04 ,$0.05 ,$0.05 ,$0.05 ,$0.02 ,$0.03 ,$0.02 ,$0.05 ,$0.04 ,$0.04 ,$0.04
Hoopeston Regional Hlth Center,9100154,ENEMA FLEET MINERAL OIL,64409,,272,$6.93 ,$6.93 ,$1.94 ,$6.34 ,$4.85 ,$5.80 ,$6.34 ,$6.34 ,$6.34 ,$2.55 ,$4.16 ,$2.08 ,$6.24 ,$5.20 ,$5.54 ,$5.75
Hoopeston Regional Hlth Center,9100154,RESECTOR AGGRESSIVE PLUS 4MM 5/bx,661,,272,$179.01 ,$179.01 ,$50.12 ,$163.79 ,$125.31 ,$149.83 ,$163.79 ,$163.79 ,$163.79 ,$65.97 ,$107.41 ,$53.70 ,$161.11 ,$134.26 ,$143.21 ,$148.58
Hoopeston Regional Hlth Center,9100154,STAPLER CONTOUR CRVD GREEN CUTTER,67430,,272,"$2,044.58 ","$2,044.58 ",$572.48 ,"$1,870.79 ","$1,431.21 ","$1,711.31 ","$1,870.79 ","$1,870.79 ","$1,870.79 ",$753.43 ,"$1,226.75 ",$613.37 ,"$1,840.12 ","$1,533.44 ","$1,635.66 ","$1,697.00 "
Hoopeston Regional Hlth Center,9100154,LOAD CONTOUR CRVD CUTTER THICK,67431,,272,"$1,150.36 ","$1,150.36 ",$322.10 ,"$1,052.58 ",$805.25 ,$962.85 ,"$1,052.58 ","$1,052.58 ","$1,052.58 ",$423.91 ,$690.22 ,$345.11 ,"$1,035.32 ",$862.77 ,$920.29 ,$954.80
Hoopeston Regional Hlth Center,9100154,CATH CHOLANGIOCATH,682,,272,$267.64 ,$267.64 ,$74.94 ,$244.89 ,$187.35 ,$224.01 ,$244.89 ,$244.89 ,$244.89 ,$98.63 ,$160.58 ,$80.29 ,$240.88 ,$200.73 ,$214.11 ,$222.14
Hoopeston Regional Hlth Center,9100154,PACK GYNE HOOPESTON 4/CA,68975,,272,$136.73 ,$136.73 ,$38.28 ,$125.11 ,$95.71 ,$114.44 ,$125.11 ,$125.11 ,$125.11 ,$50.39 ,$82.04 ,$41.02 ,$123.06 ,$102.55 ,$109.38 ,$113.49
Hoopeston Regional Hlth Center,9100154,PACK TOTAL KNEE HOOPESTON,68976,,272,$439.83 ,$439.83 ,$123.15 ,$402.44 ,$307.88 ,$368.14 ,$402.44 ,$402.44 ,$402.44 ,$162.08 ,$263.90 ,$131.95 ,$395.85 ,$329.87 ,$351.86 ,$365.06
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 24FR 5CC LATEX,696,,272,$14.97 ,$14.97 ,$4.19 ,$13.70 ,$10.48 ,$12.53 ,$13.70 ,$13.70 ,$13.70 ,$5.52 ,$8.98 ,$4.49 ,$13.47 ,$11.23 ,$11.98 ,$12.43
Hoopeston Regional Hlth Center,9100154,CANISTER SUCTION 3000CC,70,,272,$5.68 ,$5.68 ,$1.59 ,$5.20 ,$3.98 ,$4.75 ,$5.20 ,$5.20 ,$5.20 ,$2.09 ,$3.41 ,$1.70 ,$5.11 ,$4.26 ,$4.54 ,$4.71
Hoopeston Regional Hlth Center,9100154,CATH 3-WAY CONT IRR 20FR 30CC,741,,272,$36.86 ,$36.86 ,$10.32 ,$33.73 ,$25.80 ,$30.85 ,$33.73 ,$33.73 ,$33.73 ,$13.58 ,$22.12 ,$11.06 ,$33.17 ,$27.65 ,$29.49 ,$30.59
Hoopeston Regional Hlth Center,9100154,CATH 3-WAY 24FR 30CC LATEX,742,,272,$37.12 ,$37.12 ,$10.39 ,$33.96 ,$25.98 ,$31.07 ,$33.96 ,$33.96 ,$33.96 ,$13.68 ,$22.27 ,$11.14 ,$33.41 ,$27.84 ,$29.70 ,$30.81
Hoopeston Regional Hlth Center,9100154,CATH 3-WAY CONT IRR 26FR 30CC,743,,272,$77.58 ,$77.58 ,$21.72 ,$70.99 ,$54.31 ,$64.93 ,$70.99 ,$70.99 ,$70.99 ,$28.59 ,$46.55 ,$23.27 ,$69.82 ,$58.19 ,$62.06 ,$64.39
Hoopeston Regional Hlth Center,9100154,CATH COUDE FOLEY 18FR 5CC LATEX,76,,272,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9100154,DRAIN URINARY BAG 4L,775,,272,$17.46 ,$17.46 ,$4.89 ,$15.98 ,$12.22 ,$14.61 ,$15.98 ,$15.98 ,$15.98 ,$6.43 ,$10.48 ,$5.24 ,$15.71 ,$13.10 ,$13.97 ,$14.49
Hoopeston Regional Hlth Center,9100154,DRAPE C-ARM XRAY 74IN X 41IN,778,,272,$17.46 ,$17.46 ,$4.89 ,$15.98 ,$12.22 ,$14.61 ,$15.98 ,$15.98 ,$15.98 ,$6.43 ,$10.48 ,$5.24 ,$15.71 ,$13.10 ,$13.97 ,$14.49
Hoopeston Regional Hlth Center,9100154,RASP SRG SM 9.5X5.5MM XCUT RECIP,77983,,272,$276.57 ,$276.57 ,$77.44 ,$253.06 ,$193.60 ,$231.49 ,$253.06 ,$253.06 ,$253.06 ,$101.92 ,$165.94 ,$82.97 ,$248.91 ,$207.43 ,$221.26 ,$229.55
Hoopeston Regional Hlth Center,9100154,CATH FOLEY HOLDER,78,,272,$9.27 ,$9.27 ,$2.60 ,$8.48 ,$6.49 ,$7.76 ,$8.48 ,$8.48 ,$8.48 ,$3.42 ,$5.56 ,$2.78 ,$8.34 ,$6.95 ,$7.42 ,$7.69
Hoopeston Regional Hlth Center,9100154,DRAPE GYN/UROLOGY W/POUCH,789,,272,$59.13 ,$59.13 ,$16.56 ,$54.10 ,$41.39 ,$49.49 ,$54.10 ,$54.10 ,$54.10 ,$21.79 ,$35.48 ,$17.74 ,$53.22 ,$44.35 ,$47.30 ,$49.08
Hoopeston Regional Hlth Center,9100154,CATH FOLEY SILICONE 10FR 3CC,79,,272,$18.55 ,$18.55 ,$5.19 ,$16.97 ,$12.99 ,$15.53 ,$16.97 ,$16.97 ,$16.97 ,$6.84 ,$11.13 ,$5.57 ,$16.70 ,$13.91 ,$14.84 ,$15.40
Hoopeston Regional Hlth Center,9100154,PACK DILLMAN PHACO HRHC,79021,,272,"$1,136.57 ","$1,136.57 ",$318.24 ,"$1,039.96 ",$795.60 ,$951.31 ,"$1,039.96 ","$1,039.96 ","$1,039.96 ",$418.83 ,$681.94 ,$340.97 ,"$1,022.91 ",$852.43 ,$909.26 ,$943.35
Hoopeston Regional Hlth Center,9100154,BLADE BEAVER 2.2MM 45DEG DOUBLE-BEVEL,79022,,272,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9100154,KNIFE VITRECTOMY ANGLED 20GA,79025,,272,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9100154,NEEDLE CYSTOTOME 23GA X 16MM,79026,,272,$247.50 ,$247.50 ,$69.30 ,$226.46 ,$173.25 ,$207.16 ,$226.46 ,$226.46 ,$226.46 ,$91.20 ,$148.50 ,$74.25 ,$222.75 ,$185.63 ,$198.00 ,$205.43
Hoopeston Regional Hlth Center,9100154,HRHC MALYUGIN RING,79370,,272,$697.50 ,$697.50 ,$195.30 ,$638.21 ,$488.25 ,$583.81 ,$638.21 ,$638.21 ,$638.21 ,$257.03 ,$418.50 ,$209.25 ,$627.75 ,$523.13 ,$558.00 ,$578.93
Hoopeston Regional Hlth Center,9100154,HRHC DRAIN PENROSE 1-IN LATEX,79876,,272,$1.94 ,$1.94 ,$0.54 ,$1.78 ,$1.36 ,$1.62 ,$1.78 ,$1.78 ,$1.78 ,$0.71 ,$1.16 ,$0.58 ,$1.75 ,$1.46 ,$1.55 ,$1.61
Hoopeston Regional Hlth Center,9100154,STERISTRIP 1/4IN X 1-1/2IN,79877,,272,$2.30 ,$2.30 ,$0.64 ,$2.10 ,$1.61 ,$1.93 ,$2.10 ,$2.10 ,$2.10 ,$0.85 ,$1.38 ,$0.69 ,$2.07 ,$1.73 ,$1.84 ,$1.91
Hoopeston Regional Hlth Center,9100154,HRHC BSS PLUS 500ML,79878,,272,$216.00 ,$216.00 ,$60.48 ,$197.64 ,$151.20 ,$180.79 ,$197.64 ,$197.64 ,$197.64 ,$79.60 ,$129.60 ,$64.80 ,$194.40 ,$162.00 ,$172.80 ,$179.28
Hoopeston Regional Hlth Center,9100154,HRHC ANTERIOR VITRECTOMY PACK,79879,,272,$675.00 ,$675.00 ,$189.00 ,$617.63 ,$472.50 ,$564.98 ,$617.63 ,$617.63 ,$617.63 ,$248.74 ,$405.00 ,$202.50 ,$607.50 ,$506.25 ,$540.00 ,$560.25
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 12FR 5CC HYDROMER LATE,80,,272,$8.73 ,$8.73 ,$2.44 ,$7.99 ,$6.11 ,$7.31 ,$7.99 ,$7.99 ,$7.99 ,$3.22 ,$5.24 ,$2.62 ,$7.86 ,$6.55 ,$6.98 ,$7.25
Hoopeston Regional Hlth Center,9100154,ELECTRODE 6IN COAT ULTRACLEAN,800,,272,$17.01 ,$17.01 ,$4.76 ,$15.56 ,$11.91 ,$14.24 ,$15.56 ,$15.56 ,$15.56 ,$6.27 ,$10.21 ,$5.10 ,$15.31 ,$12.76 ,$13.61 ,$14.12
Hoopeston Regional Hlth Center,9100154,ELECTRODE 6IN NONCOATED FLAT USE,801,,272,$13.50 ,$13.50 ,$3.78 ,$12.35 ,$9.45 ,$11.30 ,$12.35 ,$12.35 ,$12.35 ,$4.97 ,$8.10 ,$4.05 ,$12.15 ,$10.13 ,$10.80 ,$11.21
Hoopeston Regional Hlth Center,9100154,HRHC SUCTION MANIFOLD,80391,,272,$103.05 ,$103.05 ,$28.85 ,$94.29 ,$72.14 ,$86.25 ,$94.29 ,$94.29 ,$94.29 ,$37.97 ,$61.83 ,$30.92 ,$92.75 ,$77.29 ,$82.44 ,$85.53
Hoopeston Regional Hlth Center,9100154,ELECTRODE PATIENT RETURN INFAN,806,,272,$34.54 ,$34.54 ,$9.67 ,$31.60 ,$24.18 ,$28.91 ,$31.60 ,$31.60 ,$31.60 ,$12.73 ,$20.72 ,$10.36 ,$31.09 ,$25.91 ,$27.63 ,$28.67
Hoopeston Regional Hlth Center,9100154,PENCIL ELECTROSURG BLADE TIP use,807,,272,$10.33 ,$10.33 ,$2.89 ,$9.45 ,$7.23 ,$8.65 ,$9.45 ,$9.45 ,$9.45 ,$3.81 ,$6.20 ,$3.10 ,$9.30 ,$7.75 ,$8.26 ,$8.57
Hoopeston Regional Hlth Center,9100154,HRHC STAPLER ENDO ETS45 45MM,80737,,272,$463.37 ,$463.37 ,$129.74 ,$423.98 ,$324.36 ,$387.84 ,$423.98 ,$423.98 ,$423.98 ,$170.75 ,$278.02 ,$139.01 ,$417.03 ,$347.53 ,$370.70 ,$384.60
Hoopeston Regional Hlth Center,9100154,HRHC ENDO STAPLER RELOAD 6R45B 3.5MM STANDARD ETHICON,80738,,272,$522.54 ,$522.54 ,$146.31 ,$478.12 ,$365.78 ,$437.37 ,$478.12 ,$478.12 ,$478.12 ,$192.56 ,$313.52 ,$156.76 ,$470.29 ,$391.91 ,$418.03 ,$433.71
Hoopeston Regional Hlth Center,9100154,HRHC ENDO STAPLER RELOAD TR45W 2.95MM VASCULAR ETHICON,80739,,272,$522.54 ,$522.54 ,$146.31 ,$478.12 ,$365.78 ,$437.37 ,$478.12 ,$478.12 ,$478.12 ,$192.56 ,$313.52 ,$156.76 ,$470.29 ,$391.91 ,$418.03 ,$433.71
Hoopeston Regional Hlth Center,9100154,HRHC PREP CHG PREVAIL,80740,,272,$28.76 ,$28.76 ,$8.05 ,$26.32 ,$20.13 ,$24.07 ,$26.32 ,$26.32 ,$26.32 ,$10.60 ,$17.26 ,$8.63 ,$25.88 ,$21.57 ,$23.01 ,$23.87
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 14FR 5CC HYDROMER LATE,81,,272,$8.73 ,$8.73 ,$2.44 ,$7.99 ,$6.11 ,$7.31 ,$7.99 ,$7.99 ,$7.99 ,$3.22 ,$5.24 ,$2.62 ,$7.86 ,$6.55 ,$6.98 ,$7.25
Hoopeston Regional Hlth Center,9100154,DISSECTOR BLUNT ENDOSCOPIC,811,,272,$61.88 ,$61.88 ,$17.33 ,$56.62 ,$43.32 ,$51.79 ,$56.62 ,$56.62 ,$56.62 ,$22.80 ,$37.13 ,$18.56 ,$55.69 ,$46.41 ,$49.50 ,$51.36
Hoopeston Regional Hlth Center,9100154,KIT FALOPE-RING BAND,818,,272,$397.50 ,$397.50 ,$111.30 ,$363.71 ,$278.25 ,$332.71 ,$363.71 ,$363.71 ,$363.71 ,$146.48 ,$238.50 ,$119.25 ,$357.75 ,$298.13 ,$318.00 ,$329.93
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 16FR 30CC HYDROMER LAT,82,,272,$9.27 ,$9.27 ,$2.60 ,$8.48 ,$6.49 ,$7.76 ,$8.48 ,$8.48 ,$8.48 ,$3.42 ,$5.56 ,$2.78 ,$8.34 ,$6.95 ,$7.42 ,$7.69
Hoopeston Regional Hlth Center,9100154,WIPE SKIN BARRIER PREP NO STING,8238,,272,$0.20 ,$0.20 ,$0.06 ,$0.18 ,$0.14 ,$0.17 ,$0.18 ,$0.18 ,$0.18 ,$0.07 ,$0.12 ,$0.06 ,$0.18 ,$0.15 ,$0.16 ,$0.17
Hoopeston Regional Hlth Center,9100154,FLOSEAL 5ML FOR DR. ALLY/ BROMENN,824,,272,"$1,010.62 ","$1,010.62 ",$282.97 ,$924.72 ,$707.43 ,$845.89 ,$924.72 ,$924.72 ,$924.72 ,$372.41 ,$606.37 ,$303.19 ,$909.56 ,$757.97 ,$808.50 ,$838.81
Hoopeston Regional Hlth Center,9100154,HRHC SLIT KNIFE 3.2MM ANGLED BEVEL UP,82424,,272,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9100154,BANDAGE CONFORM 2IN STRETCH GAUZE,826,,272,$0.89 ,$0.89 ,$0.25 ,$0.81 ,$0.62 ,$0.74 ,$0.81 ,$0.81 ,$0.81 ,$0.33 ,$0.53 ,$0.27 ,$0.80 ,$0.67 ,$0.71 ,$0.74
Hoopeston Regional Hlth Center,9100154,CUP MEDICINE 2OZ,829,,272,$0.86 ,$0.86 ,$0.24 ,$0.79 ,$0.60 ,$0.72 ,$0.79 ,$0.79 ,$0.79 ,$0.32 ,$0.52 ,$0.26 ,$0.77 ,$0.65 ,$0.69 ,$0.71
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 16FR 5CC HYDROMER LATE,83,,272,$8.73 ,$8.73 ,$2.44 ,$7.99 ,$6.11 ,$7.31 ,$7.99 ,$7.99 ,$7.99 ,$3.22 ,$5.24 ,$2.62 ,$7.86 ,$6.55 ,$6.98 ,$7.25
Hoopeston Regional Hlth Center,9100154,DRESSING XEROFORM PETROLEUM RL US,830,,272,$12.48 ,$12.48 ,$3.49 ,$11.42 ,$8.74 ,$10.45 ,$11.42 ,$11.42 ,$11.42 ,$4.60 ,$7.49 ,$3.74 ,$11.23 ,$9.36 ,$9.98 ,$10.36
Hoopeston Regional Hlth Center,9100154,GLOVE ESTEEM SIZE 6 USE #208820,832,,272,$9.29 ,$9.29 ,$2.60 ,$8.50 ,$6.50 ,$7.78 ,$8.50 ,$8.50 ,$8.50 ,$3.42 ,$5.57 ,$2.79 ,$8.36 ,$6.97 ,$7.43 ,$7.71
Hoopeston Regional Hlth Center,9100154,HRHC STRYKER 30 DEG CUTTING LOOP ELECTRODE 22FR,83852,,272,$472.50 ,$472.50 ,$132.30 ,$432.34 ,$330.75 ,$395.48 ,$432.34 ,$432.34 ,$432.34 ,$174.12 ,$283.50 ,$141.75 ,$425.25 ,$354.38 ,$378.00 ,$392.18
Hoopeston Regional Hlth Center,9100154,SPONGE GAUZE 2X2 2/PACK,839,,272,$0.11 ,$0.11 ,$0.03 ,$0.10 ,$0.08 ,$0.09 ,$0.10 ,$0.10 ,$0.10 ,$0.04 ,$0.07 ,$0.03 ,$0.10 ,$0.08 ,$0.09 ,$0.09
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 18FR 5CC LATEX,84,,272,$8.73 ,$8.73 ,$2.44 ,$7.99 ,$6.11 ,$7.31 ,$7.99 ,$7.99 ,$7.99 ,$3.22 ,$5.24 ,$2.62 ,$7.86 ,$6.55 ,$6.98 ,$7.25
Hoopeston Regional Hlth Center,9100154,APPLICATOR COTTON TIP 6IN 2PK USE,840,,272,$0.36 ,$0.36 ,$0.10 ,$0.33 ,$0.25 ,$0.30 ,$0.33 ,$0.33 ,$0.33 ,$0.13 ,$0.22 ,$0.11 ,$0.32 ,$0.27 ,$0.29 ,$0.30
Hoopeston Regional Hlth Center,9100154,CLIP RESOLUTION,8437,,272,"$1,317.29 ","$1,317.29 ",$368.84 ,"$1,205.32 ",$922.10 ,"$1,102.57 ","$1,205.32 ","$1,205.32 ","$1,205.32 ",$485.42 ,$790.37 ,$395.19 ,"$1,185.56 ",$987.97 ,"$1,053.83 ","$1,093.35 "
Hoopeston Regional Hlth Center,9100154,NET ROTH POLYP,8445,,272,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9100154,GLOVE ULTRAFREE MAX SIZE 8 LATEX,846,,272,$4.59 ,$4.59 ,$1.29 ,$4.20 ,$3.21 ,$3.84 ,$4.20 ,$4.20 ,$4.20 ,$1.69 ,$2.75 ,$1.38 ,$4.13 ,$3.44 ,$3.67 ,$3.81
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 20FR 30CC LATEX,85,,272,$9.27 ,$9.27 ,$2.60 ,$8.48 ,$6.49 ,$7.76 ,$8.48 ,$8.48 ,$8.48 ,$3.42 ,$5.56 ,$2.78 ,$8.34 ,$6.95 ,$7.42 ,$7.69
Hoopeston Regional Hlth Center,9100154,NET ROTH ADULT FOREIGN BODY,8517,,272,$423.00 ,$423.00 ,$118.44 ,$387.05 ,$296.10 ,$354.05 ,$387.05 ,$387.05 ,$387.05 ,$155.88 ,$253.80 ,$126.90 ,$380.70 ,$317.25 ,$338.40 ,$351.09
Hoopeston Regional Hlth Center,9100154,FORCEP JUMBO BIOPSY,8524,,272,$343.67 ,$343.67 ,$96.23 ,$314.46 ,$240.57 ,$287.65 ,$314.46 ,$314.46 ,$314.46 ,$126.64 ,$206.20 ,$103.10 ,$309.30 ,$257.75 ,$274.94 ,$285.25
Hoopeston Regional Hlth Center,9100154,HOOD STERISHIELD T5,858,,272,$112.15 ,$112.15 ,$31.40 ,$102.62 ,$78.51 ,$93.87 ,$102.62 ,$102.62 ,$102.62 ,$41.33 ,$67.29 ,$33.65 ,$100.94 ,$84.11 ,$89.72 ,$93.08
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 20FR 5CC LATEX,86,,272,$10.27 ,$10.27 ,$2.88 ,$9.40 ,$7.19 ,$8.60 ,$9.40 ,$9.40 ,$9.40 ,$3.78 ,$6.16 ,$3.08 ,$9.24 ,$7.70 ,$8.22 ,$8.52
Hoopeston Regional Hlth Center,9100154,KIT PULSAVAC PLUS SHOWER,860,,272,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9100154,SHEAR CURVED HARMONIC FOCUS,861,,272,"$1,692.90 ","$1,692.90 ",$474.01 ,"$1,549.00 ","$1,185.03 ","$1,416.96 ","$1,549.00 ","$1,549.00 ","$1,549.00 ",$623.83 ,"$1,015.74 ",$507.87 ,"$1,523.61 ","$1,269.68 ","$1,354.32 ","$1,405.11 "
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 22FR 30CC LATEX,87,,272,$16.59 ,$16.59 ,$4.65 ,$15.18 ,$11.61 ,$13.89 ,$15.18 ,$15.18 ,$15.18 ,$6.11 ,$9.95 ,$4.98 ,$14.93 ,$12.44 ,$13.27 ,$13.77
Hoopeston Regional Hlth Center,9100154,HRHC VISCOELASTIC - AMVISC / OCUCOAT / HEALON,87598,,272,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9100154,CATHETER FOLEY 14FR 5CC 2-WAY LUB,87937,,272,$26.39 ,$26.39 ,$7.39 ,$24.15 ,$18.47 ,$22.09 ,$24.15 ,$24.15 ,$24.15 ,$9.72 ,$15.83 ,$7.92 ,$23.75 ,$19.79 ,$21.11 ,$21.90
Hoopeston Regional Hlth Center,9100154,CATHETER URETERAL OLIVE TP 5FR 10,87938,,272,$53.06 ,$53.06 ,$14.86 ,$48.55 ,$37.14 ,$44.41 ,$48.55 ,$48.55 ,$48.55 ,$19.55 ,$31.84 ,$15.92 ,$47.75 ,$39.80 ,$42.45 ,$44.04
Hoopeston Regional Hlth Center,9100154,CATHETER FOLEY COATED 16FR 5CC LU,87939,,272,$14.32 ,$14.32 ,$4.01 ,$13.10 ,$10.02 ,$11.99 ,$13.10 ,$13.10 ,$13.10 ,$5.28 ,$8.59 ,$4.30 ,$12.89 ,$10.74 ,$11.46 ,$11.89
Hoopeston Regional Hlth Center,9100154,CATHETER FOLEY COATED 18FR 5CC LU,87940,,272,$14.32 ,$14.32 ,$4.01 ,$13.10 ,$10.02 ,$11.99 ,$13.10 ,$13.10 ,$13.10 ,$5.28 ,$8.59 ,$4.30 ,$12.89 ,$10.74 ,$11.46 ,$11.89
Hoopeston Regional Hlth Center,9100154,WIRE GLIDE STRAIGHT 0.35 150CM 5/,87941,,272,$169.73 ,$169.73 ,$47.52 ,$155.30 ,$118.81 ,$142.06 ,$155.30 ,$155.30 ,$155.30 ,$62.55 ,$101.84 ,$50.92 ,$152.76 ,$127.30 ,$135.78 ,$140.88
Hoopeston Regional Hlth Center,9100154,FORCEP RET STONE NIT 2.6FX90CM,87942,,272,"$1,014.75 ","$1,014.75 ",$284.13 ,$928.50 ,$710.33 ,$849.35 ,$928.50 ,$928.50 ,$928.50 ,$373.94 ,$608.85 ,$304.43 ,$913.28 ,$761.06 ,$811.80 ,$842.24
Hoopeston Regional Hlth Center,9100154,CATHETER DIL BALLON 18FX4CM,87943,,272,"$1,125.45 ","$1,125.45 ",$315.13 ,"$1,029.79 ",$787.82 ,$942.00 ,"$1,029.79 ","$1,029.79 ","$1,029.79 ",$414.73 ,$675.27 ,$337.64 ,"$1,012.91 ",$844.09 ,$900.36 ,$934.12
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 22FR 5CC LATEX,88,,272,$8.73 ,$8.73 ,$2.44 ,$7.99 ,$6.11 ,$7.31 ,$7.99 ,$7.99 ,$7.99 ,$3.22 ,$5.24 ,$2.62 ,$7.86 ,$6.55 ,$6.98 ,$7.25
Hoopeston Regional Hlth Center,9100154,CATHETER URETERAL OPEN TP 5FR 10/,88610,,272,$50.73 ,$50.73 ,$14.20 ,$46.42 ,$35.51 ,$42.46 ,$46.42 ,$46.42 ,$46.42 ,$18.69 ,$30.44 ,$15.22 ,$45.66 ,$38.05 ,$40.58 ,$42.11
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 24FR 30CC LATEX,89,,272,$16.59 ,$16.59 ,$4.65 ,$15.18 ,$11.61 ,$13.89 ,$15.18 ,$15.18 ,$15.18 ,$6.11 ,$9.95 ,$4.98 ,$14.93 ,$12.44 ,$13.27 ,$13.77
Hoopeston Regional Hlth Center,9100154,SHEAR CRV HARMONIC PISTOL 36CM,892,,272,"$2,132.36 ","$2,132.36 ",$597.06 ,"$1,951.11 ","$1,492.65 ","$1,784.79 ","$1,951.11 ","$1,951.11 ","$1,951.11 ",$785.77 ,"$1,279.42 ",$639.71 ,"$1,919.12 ","$1,599.27 ","$1,705.89 ","$1,769.86 "
Hoopeston Regional Hlth Center,9100154,MARKER BLACK W/MEDI LABELS,899,,272,$9.13 ,$9.13 ,$2.56 ,$8.35 ,$6.39 ,$7.64 ,$8.35 ,$8.35 ,$8.35 ,$3.36 ,$5.48 ,$2.74 ,$8.22 ,$6.85 ,$7.30 ,$7.58
Hoopeston Regional Hlth Center,9100154,CATH FOLEY 28FR 30CC LATEX,90,,272,$9.27 ,$9.27 ,$2.60 ,$8.48 ,$6.49 ,$7.76 ,$8.48 ,$8.48 ,$8.48 ,$3.42 ,$5.56 ,$2.78 ,$8.34 ,$6.95 ,$7.42 ,$7.69
Hoopeston Regional Hlth Center,9100154,TIP SCISSOR ENDOCUT,907,,272,$94.28 ,$94.28 ,$26.40 ,$86.27 ,$66.00 ,$78.91 ,$86.27 ,$86.27 ,$86.27 ,$34.74 ,$56.57 ,$28.28 ,$84.85 ,$70.71 ,$75.42 ,$78.25
Hoopeston Regional Hlth Center,9100154,ELECTRODE 1IN COAT NDL EXT INS,908,,272,$14.64 ,$14.64 ,$4.10 ,$13.40 ,$10.25 ,$12.25 ,$13.40 ,$13.40 ,$13.40 ,$5.39 ,$8.78 ,$4.39 ,$13.18 ,$10.98 ,$11.71 ,$12.15
Hoopeston Regional Hlth Center,9100154,COMPRESS THRP DRSFT KN WRP 2 ICE,9089,,272,$132.98 ,$132.98 ,$37.23 ,$121.68 ,$93.09 ,$111.30 ,$121.68 ,$121.68 ,$121.68 ,$49.00 ,$79.79 ,$39.89 ,$119.68 ,$99.74 ,$106.38 ,$110.37
Hoopeston Regional Hlth Center,9100003,SUTURE 2-0 VICRYL CT2 J269H,9099,,272,$7.06 ,$7.06 ,$1.98 ,$6.46 ,$4.94 ,$5.91 ,$6.46 ,$6.46 ,$6.46 ,$2.60 ,$4.24 ,$2.12 ,$6.35 ,$5.30 ,$5.65 ,$5.86
Hoopeston Regional Hlth Center,9100154,CATH FOLEY SILICONE 8FR 3ML,91,,272,$18.55 ,$18.55 ,$5.19 ,$16.97 ,$12.99 ,$15.53 ,$16.97 ,$16.97 ,$16.97 ,$6.84 ,$11.13 ,$5.57 ,$16.70 ,$13.91 ,$14.84 ,$15.40
Hoopeston Regional Hlth Center,9100003,SUTURE #1 VICRYL CTX J371H,9100,,272,$7.25 ,$7.25 ,$2.03 ,$6.63 ,$5.08 ,$6.07 ,$6.63 ,$6.63 ,$6.63 ,$2.67 ,$4.35 ,$2.18 ,$6.53 ,$5.44 ,$5.80 ,$6.02
Hoopeston Regional Hlth Center,9100154,HOLDER ARTHRO KN 30311 LTX FR,9103,,272,$48.70 ,$48.70 ,$13.64 ,$44.56 ,$34.09 ,$40.76 ,$44.56 ,$44.56 ,$44.56 ,$17.95 ,$29.22 ,$14.61 ,$43.83 ,$36.53 ,$38.96 ,$40.42
Hoopeston Regional Hlth Center,9100154,APPLICATOR CHLORAPREP 3ML,9106,,272,$3.91 ,$3.91 ,$1.09 ,$3.58 ,$2.74 ,$3.27 ,$3.58 ,$3.58 ,$3.58 ,$1.44 ,$2.35 ,$1.17 ,$3.52 ,$2.93 ,$3.13 ,$3.25
Hoopeston Regional Hlth Center,9100154,PACK ARTHROSCOPY DASC,9111,,272,$190.58 ,$190.58 ,$53.36 ,$174.38 ,$133.41 ,$159.52 ,$174.38 ,$174.38 ,$174.38 ,$70.23 ,$114.35 ,$57.17 ,$171.52 ,$142.94 ,$152.46 ,$158.18
Hoopeston Regional Hlth Center,9100154,TROCAR KII NO-BLADE 12X150MM,918,,272,$94.50 ,$94.50 ,$26.46 ,$86.47 ,$66.15 ,$79.10 ,$86.47 ,$86.47 ,$86.47 ,$34.82 ,$56.70 ,$28.35 ,$85.05 ,$70.88 ,$75.60 ,$78.44
Hoopeston Regional Hlth Center,9100154,BITEBLOCK 100/BX,9364,,272,$4.28 ,$4.28 ,$1.20 ,$3.92 ,$3.00 ,$3.58 ,$3.92 ,$3.92 ,$3.92 ,$1.58 ,$2.57 ,$1.28 ,$3.85 ,$3.21 ,$3.42 ,$3.55
Hoopeston Regional Hlth Center,9100154,APPLICATOR CHLORAPREP SEPPS,9403,,272,$1.40 ,$1.40 ,$0.39 ,$1.28 ,$0.98 ,$1.17 ,$1.28 ,$1.28 ,$1.28 ,$0.52 ,$0.84 ,$0.42 ,$1.26 ,$1.05 ,$1.12 ,$1.16
Hoopeston Regional Hlth Center,9100154,CATH ROBINSON 10FR RED RUBBER STE,95,,272,$2.89 ,$2.89 ,$0.81 ,$2.64 ,$2.02 ,$2.42 ,$2.64 ,$2.64 ,$2.64 ,$1.06 ,$1.73 ,$0.87 ,$2.60 ,$2.17 ,$2.31 ,$2.40
Hoopeston Regional Hlth Center,9100154,BANDAGE STRETCH 3IN KLING NS,9503,,272,$10.04 ,$10.04 ,$2.81 ,$9.19 ,$7.03 ,$8.40 ,$9.19 ,$9.19 ,$9.19 ,$3.70 ,$6.02 ,$3.01 ,$9.04 ,$7.53 ,$8.03 ,$8.33
Hoopeston Regional Hlth Center,9100154,DRESSING PETROLEUM GAUZE 3X9,9506,,272,$1.37 ,$1.37 ,$0.38 ,$1.25 ,$0.96 ,$1.15 ,$1.25 ,$1.25 ,$1.25 ,$0.50 ,$0.82 ,$0.41 ,$1.23 ,$1.03 ,$1.10 ,$1.14
Hoopeston Regional Hlth Center,9100154,GLOVE PROTEXIS PI LF 6 SYNTHETIC,9512,,272,$6.14 ,$6.14 ,$1.72 ,$5.62 ,$4.30 ,$5.14 ,$5.62 ,$5.62 ,$5.62 ,$2.26 ,$3.68 ,$1.84 ,$5.53 ,$4.61 ,$4.91 ,$5.10
Hoopeston Regional Hlth Center,9100154,GLOVE PROTEXIS PI LF 6.5 SYNTHETI,9513,,272,$6.14 ,$6.14 ,$1.72 ,$5.62 ,$4.30 ,$5.14 ,$5.62 ,$5.62 ,$5.62 ,$2.26 ,$3.68 ,$1.84 ,$5.53 ,$4.61 ,$4.91 ,$5.10
Hoopeston Regional Hlth Center,9100154,GLOVE PROTEXIS PI LF 8 SYNTHETIC,9514,,272,$6.14 ,$6.14 ,$1.72 ,$5.62 ,$4.30 ,$5.14 ,$5.62 ,$5.62 ,$5.62 ,$2.26 ,$3.68 ,$1.84 ,$5.53 ,$4.61 ,$4.91 ,$5.10
Hoopeston Regional Hlth Center,9100154,CUP GRADUATED MEASURE 32 OZ TRIAN,9519,,272,$9.73 ,$9.73 ,$2.72 ,$8.90 ,$6.81 ,$8.14 ,$8.90 ,$8.90 ,$8.90 ,$3.59 ,$5.84 ,$2.92 ,$8.76 ,$7.30 ,$7.78 ,$8.08
Hoopeston Regional Hlth Center,9100154,TRAY SKIN PREP CHLORHEXIDINE,953,,272,$14.37 ,$14.37 ,$4.02 ,$13.15 ,$10.06 ,$12.03 ,$13.15 ,$13.15 ,$13.15 ,$5.30 ,$8.62 ,$4.31 ,$12.93 ,$10.78 ,$11.50 ,$11.93
Hoopeston Regional Hlth Center,9100154,HOOD SURGICAL 100/BX,9530,,272,$99.99 ,$99.99 ,$28.00 ,$91.49 ,$69.99 ,$83.69 ,$91.49 ,$91.49 ,$91.49 ,$36.85 ,$59.99 ,$30.00 ,$89.99 ,$74.99 ,$79.99 ,$82.99
Hoopeston Regional Hlth Center,9100154,TRAY PRE-OP POVIDONE IODINE,954,,272,$12.96 ,$12.96 ,$3.63 ,$11.86 ,$9.07 ,$10.85 ,$11.86 ,$11.86 ,$11.86 ,$4.78 ,$7.78 ,$3.89 ,$11.66 ,$9.72 ,$10.37 ,$10.76
Hoopeston Regional Hlth Center,9100154,TRAY GEL PREP POVIDONE IODINE,955,,272,$12.51 ,$12.51 ,$3.50 ,$11.45 ,$8.76 ,$10.47 ,$11.45 ,$11.45 ,$11.45 ,$4.61 ,$7.51 ,$3.75 ,$11.26 ,$9.38 ,$10.01 ,$10.38
Hoopeston Regional Hlth Center,9100154,KIT CATH FEMALE 8FR W/GLOVE AND S,9550,,272,$6.46 ,$6.46 ,$1.81 ,$5.91 ,$4.52 ,$5.41 ,$5.91 ,$5.91 ,$5.91 ,$2.38 ,$3.88 ,$1.94 ,$5.81 ,$4.85 ,$5.17 ,$5.36
Hoopeston Regional Hlth Center,9100154,CATH ROBINSON 12FR RED RUBBER STE,96,,272,$2.89 ,$2.89 ,$0.81 ,$2.64 ,$2.02 ,$2.42 ,$2.64 ,$2.64 ,$2.64 ,$1.06 ,$1.73 ,$0.87 ,$2.60 ,$2.17 ,$2.31 ,$2.40
Hoopeston Regional Hlth Center,9100154,NEEDLE SAFETY 18GX1.5IN ECLIPSE 1,9604,,272,$0.66 ,$0.66 ,$0.18 ,$0.60 ,$0.46 ,$0.55 ,$0.60 ,$0.60 ,$0.60 ,$0.24 ,$0.40 ,$0.20 ,$0.59 ,$0.50 ,$0.53 ,$0.55
Hoopeston Regional Hlth Center,9100154,NEEDLE SAFETY ECLIPS 25GX5/8IN EC,9609,,272,$0.66 ,$0.66 ,$0.18 ,$0.60 ,$0.46 ,$0.55 ,$0.60 ,$0.60 ,$0.60 ,$0.24 ,$0.40 ,$0.20 ,$0.59 ,$0.50 ,$0.53 ,$0.55
Hoopeston Regional Hlth Center,9100154,PACK OR C-SECTION CUSTOM 2/case,9628,,272,$360.23 ,$360.23 ,$100.86 ,$329.61 ,$252.16 ,$301.51 ,$329.61 ,$329.61 ,$329.61 ,$132.74 ,$216.14 ,$108.07 ,$324.21 ,$270.17 ,$288.18 ,$298.99
Hoopeston Regional Hlth Center,9100154,STRIP PACKING IODOFORM 2IN,9632,,272,$12.69 ,$12.69 ,$3.55 ,$11.61 ,$8.88 ,$10.62 ,$11.61 ,$11.61 ,$11.61 ,$4.68 ,$7.61 ,$3.81 ,$11.42 ,$9.52 ,$10.15 ,$10.53
Hoopeston Regional Hlth Center,9100154,STRIP PACKING PLAIN 0.25IN,9633,,272,$6.40 ,$6.40 ,$1.79 ,$5.86 ,$4.48 ,$5.36 ,$5.86 ,$5.86 ,$5.86 ,$2.36 ,$3.84 ,$1.92 ,$5.76 ,$4.80 ,$5.12 ,$5.31
Hoopeston Regional Hlth Center,9100154,RETAINER VISCERA FISH,964,,272,$85.20 ,$85.20 ,$23.86 ,$77.96 ,$59.64 ,$71.31 ,$77.96 ,$77.96 ,$77.96 ,$31.40 ,$51.12 ,$25.56 ,$76.68 ,$63.90 ,$68.16 ,$70.72
Hoopeston Regional Hlth Center,9100154,NEEDLE ACUJET FLEX,9675,,272,$153.00 ,$153.00 ,$42.84 ,$140.00 ,$107.10 ,$128.06 ,$140.00 ,$140.00 ,$140.00 ,$56.38 ,$91.80 ,$45.90 ,$137.70 ,$114.75 ,$122.40 ,$126.99
Hoopeston Regional Hlth Center,9100154,SET SECONDARY IV MIDLENGTH 34 INC,9683,,272,$4.21 ,$4.21 ,$1.18 ,$3.85 ,$2.95 ,$3.52 ,$3.85 ,$3.85 ,$3.85 ,$1.55 ,$2.53 ,$1.26 ,$3.79 ,$3.16 ,$3.37 ,$3.49
Hoopeston Regional Hlth Center,9100154,SET PRIMARY IV PIGGYBACK 100IN,9687,,272,$14.14 ,$14.14 ,$3.96 ,$12.94 ,$9.90 ,$11.84 ,$12.94 ,$12.94 ,$12.94 ,$5.21 ,$8.48 ,$4.24 ,$12.73 ,$10.61 ,$11.31 ,$11.74
Hoopeston Regional Hlth Center,9100154,SET PCA INJECTOR MINIBORE,9688,,272,$22.13 ,$22.13 ,$6.20 ,$20.25 ,$15.49 ,$18.52 ,$20.25 ,$20.25 ,$20.25 ,$8.15 ,$13.28 ,$6.64 ,$19.92 ,$16.60 ,$17.70 ,$18.37
Hoopeston Regional Hlth Center,9100154,SHOE WALKING ORTHO XS DARCO,9695,,272,$61.02 ,$61.02 ,$17.09 ,$55.83 ,$42.71 ,$51.07 ,$55.83 ,$55.83 ,$55.83 ,$22.49 ,$36.61 ,$18.31 ,$54.92 ,$45.77 ,$48.82 ,$50.65
Hoopeston Regional Hlth Center,9100154,SHOE WALKING ORTHO MD DARCO,9696,,272,$61.61 ,$61.61 ,$17.25 ,$56.37 ,$43.13 ,$51.57 ,$56.37 ,$56.37 ,$56.37 ,$22.70 ,$36.97 ,$18.48 ,$55.45 ,$46.21 ,$49.29 ,$51.14
Hoopeston Regional Hlth Center,9100154,SHOE WALKING ORTHO LG DARCO,9697,,272,$61.56 ,$61.56 ,$17.24 ,$56.33 ,$43.09 ,$51.53 ,$56.33 ,$56.33 ,$56.33 ,$22.68 ,$36.94 ,$18.47 ,$55.40 ,$46.17 ,$49.25 ,$51.09
Hoopeston Regional Hlth Center,9100154,CATH ROBINSON 14FR RED RUBBER STE,97,,272,$2.89 ,$2.89 ,$0.81 ,$2.64 ,$2.02 ,$2.42 ,$2.64 ,$2.64 ,$2.64 ,$1.06 ,$1.73 ,$0.87 ,$2.60 ,$2.17 ,$2.31 ,$2.40
Hoopeston Regional Hlth Center,9100154,DRAPE BILATERAL LIMB W/COVER,971,,272,$31.35 ,$31.35 ,$8.78 ,$28.69 ,$21.95 ,$26.24 ,$28.69 ,$28.69 ,$28.69 ,$11.55 ,$18.81 ,$9.41 ,$28.22 ,$23.51 ,$25.08 ,$26.02
Hoopeston Regional Hlth Center,9100154,DRAPE PEDATRIC LAPAROTOMY,972,,272,$17.14 ,$17.14 ,$4.80 ,$15.68 ,$12.00 ,$14.35 ,$15.68 ,$15.68 ,$15.68 ,$6.32 ,$10.28 ,$5.14 ,$15.43 ,$12.86 ,$13.71 ,$14.23
Hoopeston Regional Hlth Center,9100154,SOL IRR .9 NACL 250ML 24/CASE,9727,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL IRR .9 NACL 500ML 24/CASE,9728,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,DRAPE SPLIT SHEET,973,,272,$20.43 ,$20.43 ,$5.72 ,$18.69 ,$14.30 ,$17.10 ,$18.69 ,$18.69 ,$18.69 ,$7.53 ,$12.26 ,$6.13 ,$18.39 ,$15.32 ,$16.34 ,$16.96
Hoopeston Regional Hlth Center,9100154,SOL IRR WATER 1500ML,9731,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SOL IRR WATER 500ML 24/CASE,9733,,272,$71.95 ,$71.95 ,$20.15 ,$65.83 ,$50.37 ,$60.22 ,$65.83 ,$65.83 ,$65.83 ,$26.51 ,$43.17 ,$21.59 ,$64.76 ,$53.96 ,$57.56 ,$59.72
Hoopeston Regional Hlth Center,9100154,SPONGE GAUZE 2 X 2 8-PLY STERILE,9753,,272,$0.10 ,$0.10 ,$0.03 ,$0.09 ,$0.07 ,$0.08 ,$0.09 ,$0.09 ,$0.09 ,$0.04 ,$0.06 ,$0.03 ,$0.09 ,$0.08 ,$0.08 ,$0.08
Hoopeston Regional Hlth Center,9100154,SPONGE GAUZE 4 X 4 8-PLY STERILE,9754,,272,$0.23 ,$0.23 ,$0.06 ,$0.21 ,$0.16 ,$0.19 ,$0.21 ,$0.21 ,$0.21 ,$0.08 ,$0.14 ,$0.07 ,$0.21 ,$0.17 ,$0.18 ,$0.19
Hoopeston Regional Hlth Center,9100154,SLEEVE CONVERTER STERILE,977,,272,$2.81 ,$2.81 ,$0.79 ,$2.57 ,$1.97 ,$2.35 ,$2.57 ,$2.57 ,$2.57 ,$1.04 ,$1.69 ,$0.84 ,$2.53 ,$2.11 ,$2.25 ,$2.33
Hoopeston Regional Hlth Center,9100154,STERISTRIP 1/8IN X 3IN,9777,,272,$2.22 ,$2.22 ,$0.62 ,$2.03 ,$1.55 ,$1.86 ,$2.03 ,$2.03 ,$2.03 ,$0.82 ,$1.33 ,$0.67 ,$2.00 ,$1.67 ,$1.78 ,$1.84
Hoopeston Regional Hlth Center,9100154,STOCKING COMPR THIGH SMALL SHORT,9785,,272,$15.80 ,$15.80 ,$4.42 ,$14.46 ,$11.06 ,$13.22 ,$14.46 ,$14.46 ,$14.46 ,$5.82 ,$9.48 ,$4.74 ,$14.22 ,$11.85 ,$12.64 ,$13.11
Hoopeston Regional Hlth Center,9100154,CATH ROBINSON 16FR RED RUBBER STE,98,,272,$2.89 ,$2.89 ,$0.81 ,$2.64 ,$2.02 ,$2.42 ,$2.64 ,$2.64 ,$2.64 ,$1.06 ,$1.73 ,$0.87 ,$2.60 ,$2.17 ,$2.31 ,$2.40
Hoopeston Regional Hlth Center,9100154,SWABSTICK BENZOIN TINCTURE 500/CA,9804,,272,$1.51 ,$1.51 ,$0.42 ,$1.38 ,$1.06 ,$1.26 ,$1.38 ,$1.38 ,$1.38 ,$0.56 ,$0.91 ,$0.45 ,$1.36 ,$1.13 ,$1.21 ,$1.25
Hoopeston Regional Hlth Center,9100154,SYRINGE INSULIN 1/2ML 31GA 6MM 10,9806,,272,$1.18 ,$1.18 ,$0.33 ,$1.08 ,$0.83 ,$0.99 ,$1.08 ,$1.08 ,$1.08 ,$0.43 ,$0.71 ,$0.35 ,$1.06 ,$0.89 ,$0.94 ,$0.98
Hoopeston Regional Hlth Center,9100154,SYRINGE SFTY INS 29GA .5IN 1ML,9807,,272,$1.20 ,$1.20 ,$0.34 ,$1.10 ,$0.84 ,$1.00 ,$1.10 ,$1.10 ,$1.10 ,$0.44 ,$0.72 ,$0.36 ,$1.08 ,$0.90 ,$0.96 ,$1.00
Hoopeston Regional Hlth Center,9100154,KIT PEG 24FR SAFETY PULL,9873,,272,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9100154,SPONGE LAPAROTOMY 8 X 36IN,989,,272,$12.63 ,$12.63 ,$3.54 ,$11.56 ,$8.84 ,$10.57 ,$11.56 ,$11.56 ,$11.56 ,$4.65 ,$7.58 ,$3.79 ,$11.37 ,$9.47 ,$10.10 ,$10.48
Hoopeston Regional Hlth Center,9100154,CATH ROBINSON 18FR RED RUBBER STE,99,,272,$2.89 ,$2.89 ,$0.81 ,$2.64 ,$2.02 ,$2.42 ,$2.64 ,$2.64 ,$2.64 ,$1.06 ,$1.73 ,$0.87 ,$2.60 ,$2.17 ,$2.31 ,$2.40
Hoopeston Regional Hlth Center,9100154,SYRINGE PREFLL 3ML NACL FLUSH 2.5,9990,,272,$0.90 ,$0.90 ,$0.25 ,$0.82 ,$0.63 ,$0.75 ,$0.82 ,$0.82 ,$0.82 ,$0.33 ,$0.54 ,$0.27 ,$0.81 ,$0.68 ,$0.72 ,$0.75
Hoopeston Regional Hlth Center,9100154,SYRINGE 10ML NACL FLUSH 30/BX PRE,9991,,272,$0.91 ,$0.91 ,$0.25 ,$0.83 ,$0.64 ,$0.76 ,$0.83 ,$0.83 ,$0.83 ,$0.34 ,$0.55 ,$0.27 ,$0.82 ,$0.68 ,$0.73 ,$0.76
Hoopeston Regional Hlth Center,9670007,"BANDAGE 2"" EA.",,,273,$6.00 ,$6.00 ,$1.68 ,$5.49 ,$4.20 ,$5.02 ,$5.49 ,$5.49 ,$5.49 ,$2.21 ,$3.60 ,$1.80 ,$5.40 ,$4.50 ,$4.80 ,$4.98
Hoopeston Regional Hlth Center,9670008,"BANDAGE 3"" EA.",,,273,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9670009,"BANDAGE 4"" EA.",,,273,$10.00 ,$10.00 ,$2.80 ,$9.15 ,$7.00 ,$8.37 ,$9.15 ,$9.15 ,$9.15 ,$3.69 ,$6.00 ,$3.00 ,$9.00 ,$7.50 ,$8.00 ,$8.30
Hoopeston Regional Hlth Center,9670010,"BANDAGE 6"" EA.",,,273,$13.00 ,$13.00 ,$3.64 ,$11.90 ,$9.10 ,$10.88 ,$11.90 ,$11.90 ,$11.90 ,$4.79 ,$7.80 ,$3.90 ,$11.70 ,$9.75 ,$10.40 ,$10.79
Hoopeston Regional Hlth Center,9670024,BANDAGE 10 CM. EA.,,,273,$7.00 ,$7.00 ,$1.96 ,$6.41 ,$4.90 ,$5.86 ,$6.41 ,$6.41 ,$6.41 ,$2.58 ,$4.20 ,$2.10 ,$6.30 ,$5.25 ,$5.60 ,$5.81
Hoopeston Regional Hlth Center,9670025,BANDAGE 15 CM. EA.,,,273,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9670029,WALKING BOOT EA.,,,273,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9670033,CANE BRONZE W/ORTHO GRIP,,,273,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9670034,CANE QUAD SMALL/LARGE BASE,,,273,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,9670035,CANE STANDARD,,,273,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,9670036,CERVICAL ROLL,,,273,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9670037,CERVICAL ROLL REGULAR,,,273,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9670038,CERVICAL TRACTION KIT,,,273,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9670041,"BANDAGE 1"" PER ROLL",,,273,$4.00 ,$4.00 ,$1.12 ,$3.66 ,$2.80 ,$3.35 ,$3.66 ,$3.66 ,$3.66 ,$1.47 ,$2.40 ,$1.20 ,$3.60 ,$3.00 ,$3.20 ,$3.32
Hoopeston Regional Hlth Center,9670042,"BANDAGE 2"" PER ROLL",,,273,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9670043,"COVER ROLL 2"" BX",,,273,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9670046,CPM SLINGSET EA,,,273,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9670047,CRUTCHES PR,,,273,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9670066,ELECTRODES FOR E-STIM EA,,,273,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9670067,ELECTRODE-STIM OVAL 2X4 EA,,,273,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9670069,EXTNSR PATELLAR STAB KNEE WRAP,,,273,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9670072,FIBROMYALGIA BOOK,,,273,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9670077,FOOT DROP SPLINT,,,273,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9670079,GAIT BELT 48 INCH,,,273,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9670080,GAIT BELT 60 INCH,,,273,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9670081,GAIT BELT 72 INCH,,,273,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9670082,ELBOW BRACE,,,273,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9670083,GLOVE EDEMA EA,,,273,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9670084,GLOVE GEL EA,,,273,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9670085,GLOVE EA,,,273,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9670087,"GREY FOAM 1/2"" SHEET PER SHEET",,,273,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9670088,"GREY FOAM 1/4"" SHEET PER SHEET",,,273,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9670089,HALF LUMBAR ROLL,,,273,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9670092,HAND EXERCISER EA,,,273,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9670100,ARM SLING,,,273,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9670101,HOME PULLEY MET EA,,,273,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9670102,HOME PULLEY EACH,,,273,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9670108,ADHESIVE LOTION,,,273,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9670109,K1 10M PER YD.,,,273,$4.00 ,$4.00 ,$1.12 ,$3.66 ,$2.80 ,$3.35 ,$3.66 ,$3.66 ,$3.66 ,$1.47 ,$2.40 ,$1.20 ,$3.60 ,$3.00 ,$3.20 ,$3.32
Hoopeston Regional Hlth Center,9670110,KIDNEY LARGE EA,,,273,$7.00 ,$7.00 ,$1.96 ,$6.41 ,$4.90 ,$5.86 ,$6.41 ,$6.41 ,$6.41 ,$2.58 ,$4.20 ,$2.10 ,$6.30 ,$5.25 ,$5.60 ,$5.81
Hoopeston Regional Hlth Center,9670111,KIDNEY SMALL EA,,,273,$5.00 ,$5.00 ,$1.40 ,$4.58 ,$3.50 ,$4.19 ,$4.58 ,$4.58 ,$4.58 ,$1.84 ,$3.00 ,$1.50 ,$4.50 ,$3.75 ,$4.00 ,$4.15
Hoopeston Regional Hlth Center,9670112,KNEE BRACE LG NEOPRENE PULLOVE,,,273,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9670113,KT MEDICAL GLOVE,,,273,$44.00 ,$44.00 ,$12.32 ,$40.26 ,$30.80 ,$36.83 ,$40.26 ,$40.26 ,$40.26 ,$16.21 ,$26.40 ,$13.20 ,$39.60 ,$33.00 ,$35.20 ,$36.52
Hoopeston Regional Hlth Center,9670114,LUMBAR ROLL,,,273,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9670115,LUMBAR SACRAL SADDLE,,,273,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9670116,"LUMBAR SUPPORT 28-37""",,,273,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9670118,MANAGING BACK PAIN,,,273,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9670120,BANDAGE 4CM ROLL,,,273,$3.00 ,$3.00 ,$0.84 ,$2.75 ,$2.10 ,$2.51 ,$2.75 ,$2.75 ,$2.75 ,$1.11 ,$1.80 ,$0.90 ,$2.70 ,$2.25 ,$2.40 ,$2.49
Hoopeston Regional Hlth Center,9670121,BANDAGE 6CM ROLL,,,273,$4.00 ,$4.00 ,$1.12 ,$3.66 ,$2.80 ,$3.35 ,$3.66 ,$3.66 ,$3.66 ,$1.47 ,$2.40 ,$1.20 ,$3.60 ,$3.00 ,$3.20 ,$3.32
Hoopeston Regional Hlth Center,9670126,NECK EXERCISER STP,,,273,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9670127,NEONATAL KIT,,,273,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9670134,PLATFORM CRX. ATTACHMENT EA,,,273,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9670138,BANDAGE SYSTEM BX,,,273,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9670145,BANDAGE 10CM EA,,,273,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9670146,BANDAGE 12CM EA,,,273,$28.00 ,$28.00 ,$7.84 ,$25.62 ,$19.60 ,$23.44 ,$25.62 ,$25.62 ,$25.62 ,$10.32 ,$16.80 ,$8.40 ,$25.20 ,$21.00 ,$22.40 ,$23.24
Hoopeston Regional Hlth Center,9670147,BANDAGE 6CM EA,,,273,$13.00 ,$13.00 ,$3.64 ,$11.90 ,$9.10 ,$10.88 ,$11.90 ,$11.90 ,$11.90 ,$4.79 ,$7.80 ,$3.90 ,$11.70 ,$9.75 ,$10.40 ,$10.79
Hoopeston Regional Hlth Center,9670148,BANDAGE 8CM EA,,,273,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9670149,BANDAGE SOFT 10CM/BOX,,,273,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9670150,BANDAGE SOFT 15CM/BOX,,,273,$28.00 ,$28.00 ,$7.84 ,$25.62 ,$19.60 ,$23.44 ,$25.62 ,$25.62 ,$25.62 ,$10.32 ,$16.80 ,$8.40 ,$25.20 ,$21.00 ,$22.40 ,$23.24
Hoopeston Regional Hlth Center,9670152,SCAR PATCH-LARGE,,,273,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9670153,SCAR PATCH-MEDIUM,,,273,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9670154,SCAR PATCH-SMALL,,,273,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9670155,"CASTING TAPE 2""",,,273,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9670156,"CASTING TAPE 3""",,,273,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9670157,"CASTING TAPE 4""",,,273,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9670158,"CASTING TAPE 5""",,,273,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9670159,SEX AND BACK PAIN BOOK,,,273,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9670164,SLING ARM COMFORT,,,273,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9670165,LUMBAR SUPPORT BRACE,,,273,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9670174,BANDAGE 6/20M YD,,,273,$5.00 ,$5.00 ,$1.40 ,$4.58 ,$3.50 ,$4.19 ,$4.58 ,$4.58 ,$4.58 ,$1.84 ,$3.00 ,$1.50 ,$4.50 ,$3.75 ,$4.00 ,$4.15
Hoopeston Regional Hlth Center,9670175,BANDAGE 7/20M YD,,,273,$5.00 ,$5.00 ,$1.40 ,$4.58 ,$3.50 ,$4.19 ,$4.58 ,$4.58 ,$4.58 ,$1.84 ,$3.00 ,$1.50 ,$4.50 ,$3.75 ,$4.00 ,$4.15
Hoopeston Regional Hlth Center,9670176,BANDAGE 9/20M YD,,,273,$5.00 ,$5.00 ,$1.40 ,$4.58 ,$3.50 ,$4.19 ,$4.58 ,$4.58 ,$4.58 ,$1.84 ,$3.00 ,$1.50 ,$4.50 ,$3.75 ,$4.00 ,$4.15
Hoopeston Regional Hlth Center,9670177,GAUZE 2IN. ROLL,,,273,$5.00 ,$5.00 ,$1.40 ,$4.58 ,$3.50 ,$4.19 ,$4.58 ,$4.58 ,$4.58 ,$1.84 ,$3.00 ,$1.50 ,$4.50 ,$3.75 ,$4.00 ,$4.15
Hoopeston Regional Hlth Center,9670182,WALKER ADULT FOLDING,,,273,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9670183,WALKER WHEELS 5 INCHES PER PAIR,,,273,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9670184,WORK BOOK WITHOUT TEARS,,,273,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9670185,ANCHOR BELT,,,273,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9670013,AFO NIGHT SPLINT/ADULT,,L4396,274,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9670018,AFO/REG STYLE,,L1960,274,$622.00 ,$622.00 ,$174.16 ,$569.13 ,$435.40 ,$520.61 ,$569.13 ,$569.13 ,$569.13 ,$229.21 ,$373.20 ,$186.60 ,$559.80 ,$466.50 ,$497.60 ,$516.26
Hoopeston Regional Hlth Center,9670040,"CMC STABILIZATION ""Y"" SPLINT",,L3919,274,$247.00 ,$247.00 ,$69.16 ,$226.01 ,$172.90 ,$206.74 ,$226.01 ,$226.01 ,$226.01 ,$91.02 ,$148.20 ,$74.10 ,$222.30 ,$185.25 ,$197.60 ,$205.01
Hoopeston Regional Hlth Center,9670051,CUSTOM ORTHOTIC-LARGE,,L3000,274,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9670052,CUSTOM ORTHOTIC-MEDIUM,,L3000,274,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9670053,CUSTOM ORTHOTIC-SMALL,,L3000,274,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9670054,DAFO W/ FREE MED LAT STAB,,L1960,274,$622.00 ,$622.00 ,$174.16 ,$569.13 ,$435.40 ,$520.61 ,$569.13 ,$569.13 ,$569.13 ,$229.21 ,$373.20 ,$186.60 ,$559.80 ,$466.50 ,$497.60 ,$516.26
Hoopeston Regional Hlth Center,9670055,DAFO W/FREE PLANTAR FLEXION,,L1960,274,$622.00 ,$622.00 ,$174.16 ,$569.13 ,$435.40 ,$520.61 ,$569.13 ,$569.13 ,$569.13 ,$229.21 ,$373.20 ,$186.60 ,$559.80 ,$466.50 ,$497.60 ,$516.26
Hoopeston Regional Hlth Center,9670056,DIGIT ARTHR DYN MCP EXT SPLINT,,L3806,274,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9670057,DURAN STATIC DORSAL BLOCKING,,L3808,274,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9670058,DYNAMIC SUP./PRO.SPLINT,,L3764,274,$715.00 ,$715.00 ,$200.20 ,$654.23 ,$500.50 ,$598.46 ,$654.23 ,$654.23 ,$654.23 ,$263.48 ,$429.00 ,$214.50 ,$643.50 ,$536.25 ,$572.00 ,$593.45
Hoopeston Regional Hlth Center,9670059,DYNAMIC WRIST SPLINT,,L3905,274,$905.00 ,$905.00 ,$253.40 ,$828.08 ,$633.50 ,$757.49 ,$828.08 ,$828.08 ,$828.08 ,$333.49 ,$543.00 ,$271.50 ,$814.50 ,$678.75 ,$724.00 ,$751.15
Hoopeston Regional Hlth Center,9670070,FB DYNAMIC MP FLEXION SPLINT,,L3806,274,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9670073,FINGER GUTTER SPLINT,,L3933,274,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9670074,FINGERTIP PROTECTOR,,L3933,274,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9670076,FOOT DROP MODERATE CONTROL,,L1960,274,$622.00 ,$622.00 ,$174.16 ,$569.13 ,$435.40 ,$520.61 ,$569.13 ,$569.13 ,$569.13 ,$229.21 ,$373.20 ,$186.60 ,$559.80 ,$466.50 ,$497.60 ,$516.26
Hoopeston Regional Hlth Center,9670078,FOREARM BASE THUMB SPICA GAUNT,,L3808,274,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9670090,HAND ARTHRP DYN MCP EXT SPLNT,,L3806,274,$475.00 ,$475.00 ,$133.00 ,$434.63 ,$332.50 ,$397.58 ,$434.63 ,$434.63 ,$434.63 ,$175.04 ,$285.00 ,$142.50 ,$427.50 ,$356.25 ,$380.00 ,$394.25
Hoopeston Regional Hlth Center,9670091,HAND BASED THUMB SPICA (WHFO),,L3913,274,$247.00 ,$247.00 ,$69.16 ,$226.01 ,$172.90 ,$206.74 ,$226.01 ,$226.01 ,$226.01 ,$91.02 ,$148.20 ,$74.10 ,$222.30 ,$185.25 ,$197.60 ,$205.01
Hoopeston Regional Hlth Center,9670093,HB DYNAMIC IP EXTENSION SPLINT,,L3921,274,$293.00 ,$293.00 ,$82.04 ,$268.10 ,$205.10 ,$245.24 ,$268.10 ,$268.10 ,$268.10 ,$107.97 ,$175.80 ,$87.90 ,$263.70 ,$219.75 ,$234.40 ,$243.19
Hoopeston Regional Hlth Center,9670094,HB DYNAMIC IP FLEXION SPLINT,,L3921,274,$293.00 ,$293.00 ,$82.04 ,$268.10 ,$205.10 ,$245.24 ,$268.10 ,$268.10 ,$268.10 ,$107.97 ,$175.80 ,$87.90 ,$263.70 ,$219.75 ,$234.40 ,$243.19
Hoopeston Regional Hlth Center,9670095,HB MP/IP EXTNSION BLOCK SPLINT,,L3913,274,$247.00 ,$247.00 ,$69.16 ,$226.01 ,$172.90 ,$206.74 ,$226.01 ,$226.01 ,$226.01 ,$91.02 ,$148.20 ,$74.10 ,$222.30 ,$185.25 ,$197.60 ,$205.01
Hoopeston Regional Hlth Center,9670096,HB PALMER RESTING SPLINT,,L3913,274,$247.00 ,$247.00 ,$69.16 ,$226.01 ,$172.90 ,$206.74 ,$226.01 ,$226.01 ,$226.01 ,$91.02 ,$148.20 ,$74.10 ,$222.30 ,$185.25 ,$197.60 ,$205.01
Hoopeston Regional Hlth Center,9670097,HB PST-DUPYTRNS FNGR EXT SPLNT,,L3913,274,$247.00 ,$247.00 ,$69.16 ,$226.01 ,$172.90 ,$206.74 ,$226.01 ,$226.01 ,$226.01 ,$91.02 ,$148.20 ,$74.10 ,$222.30 ,$185.25 ,$197.60 ,$205.01
Hoopeston Regional Hlth Center,9670098,HB STATIC PROGR IP FLEXN SPLNT,,L3935,274,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9670099,HB ULNAR/RADIAL GUTTER SPLINT,,L3913,274,$247.00 ,$247.00 ,$69.16 ,$226.01 ,$172.90 ,$206.74 ,$226.01 ,$226.01 ,$226.01 ,$91.02 ,$148.20 ,$74.10 ,$222.30 ,$185.25 ,$197.60 ,$205.01
Hoopeston Regional Hlth Center,9670117,MALLET SPLINT,,L3933,274,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9670135,POST DUYPTRNS RELEASE-FING EXT,,L3808,274,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9670141,RA RESTING HAND,,L3808,274,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9670142,RADIAL N DYN MCP EXTNSN SPLINT,,L3806,274,$475.00 ,$475.00 ,$133.00 ,$434.63 ,$332.50 ,$397.58 ,$434.63 ,$434.63 ,$434.63 ,$175.04 ,$285.00 ,$142.50 ,$427.50 ,$356.25 ,$380.00 ,$394.25
Hoopeston Regional Hlth Center,9670143,RESTING PAN,,L3808,274,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9670167,STATIC LONG ARM ELBOW SPLINT,,L3702,274,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,9670168,STATIC-PROGRESSIVE WRIST BASE,,L3905,274,$905.00 ,$905.00 ,$253.40 ,$828.08 ,$633.50 ,$757.49 ,$828.08 ,$828.08 ,$828.08 ,$333.49 ,$543.00 ,$271.50 ,$814.50 ,$678.75 ,$724.00 ,$751.15
Hoopeston Regional Hlth Center,9670173,SUGAR TONG SPLINT,,L3763,274,$683.00 ,$683.00 ,$191.24 ,$624.95 ,$478.10 ,$571.67 ,$624.95 ,$624.95 ,$624.95 ,$251.69 ,$409.80 ,$204.90 ,$614.70 ,$512.25 ,$546.40 ,$566.89
Hoopeston Regional Hlth Center,9670178,UE LONG ARM ELBOW FX SPLINT,,L3702,274,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,9670179,"ULNAR N. ANTI - CLAW ""8""",,L3913,274,$247.00 ,$247.00 ,$69.16 ,$226.01 ,$172.90 ,$206.74 ,$226.01 ,$226.01 ,$226.01 ,$91.02 ,$148.20 ,$74.10 ,$222.30 ,$185.25 ,$197.60 ,$205.01
Hoopeston Regional Hlth Center,9670186,WRST GAUNT MOLD VOLR/DRSL/THMB,,L3906,274,$463.00 ,$463.00 ,$129.64 ,$423.65 ,$324.10 ,$387.53 ,$423.65 ,$423.65 ,$423.65 ,$170.62 ,$277.80 ,$138.90 ,$416.70 ,$347.25 ,$370.40 ,$384.29
Hoopeston Regional Hlth Center,9670205,HB STATIC PROGR IP EXTSN SPLNT,,L3933,274,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9680001,BELOW KNEE 18-30 MMHG,,A6530,274,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9680003,ARM SLEEVE EA.,,A6543,274,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9680005,CERVICAL COLLAR (SM.MED. LARGE,,L0120,274,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9680006,KTR STAB KNEE WRAP W/DER STRAP,,L1800,274,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9680007,KNEE BRACE LG STABILIZER HS,,L1800,274,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9680008,KNEE BRACE LG HINGED STABILIZ,,L1810,274,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9680009,KNEE STRAP CHO-PAT,,L1825,274,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9680010,KNEE IMMOBILIZER FULL EXT,,L1830,274,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9680011,ROCKETSOC EA,,L1906,274,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9680012,ANKLE AIR CAST EA.,,L1930,274,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,9680013,DORSI WEDGE SPLINT,,L1930,274,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9680014,PREFAB AFO,,L1930,274,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9680015,POST OP/DARCO SHOE,,L3260,274,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9680016,HEEL/ELBOW PROTECTOR,,L3700,274,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9680017,ELBOW FLOTATION PAD,,L3700,274,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9680018,NEOPRENE ELBOW SLEEVE,,L3700,274,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9680019,ARMBAND AIRCAST PNEUMATIC EA.,,L3700,274,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,9680020,ELBOW FLOTATION PAD REGULAR EA,,L3700,274,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9680021,ELBOW BRACE BAND-IT EA,,L3700,274,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9680022,EPITRAIN ELBOW SPLINT NATURAL,,L3700,274,$80.00 ,$80.00 ,$22.40 ,$73.20 ,$56.00 ,$66.96 ,$73.20 ,$73.20 ,$73.20 ,$29.48 ,$48.00 ,$24.00 ,$72.00 ,$60.00 ,$64.00 ,$66.40
Hoopeston Regional Hlth Center,9680023,ARTICULATING ELBOW BRACE,,L3760,274,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9680024,PRE-FABRICATED LONG ARM ELBOW,,L3762,274,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9680025,THUMB SPICA W/CARLE LOGO,,L3807,274,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9680026,WRIST SPLINT THUMBOFORM OTTOBO,,L3807,274,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9680027,ANTI-SPASTICITY SPREADING HAND,,L3807,274,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9680029,ALIGN RITE WRIST BRACE SHORT,,L3908,274,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9680030,GLOVE FINGER FLEXION,,L3912,274,$80.00 ,$80.00 ,$22.40 ,$73.20 ,$56.00 ,$66.96 ,$73.20 ,$73.20 ,$73.20 ,$29.48 ,$48.00 ,$24.00 ,$72.00 ,$60.00 ,$64.00 ,$66.40
Hoopeston Regional Hlth Center,9680031,JOE COOL,,L3923,274,$40.00 ,$40.00 ,$11.20 ,$36.60 ,$28.00 ,$33.48 ,$36.60 ,$36.60 ,$36.60 ,$14.74 ,$24.00 ,$12.00 ,$36.00 ,$30.00 ,$32.00 ,$33.20
Hoopeston Regional Hlth Center,9680032,FREEDOM THUMBFIT,,L3923,274,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9680033,BENIK,,L3923,274,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9680034,PIP/DIP FINGER FLEXION STRAP,,L3925,274,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9680035,BUDDY STRAP,,L3925,274,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9680036,PIP SOF-TOUCH EXT SPLINT,,L3925,274,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9680037,STAX/MALLET SPLINT,,L3927,274,$8.00 ,$8.00 ,$2.24 ,$7.32 ,$5.60 ,$6.70 ,$7.32 ,$7.32 ,$7.32 ,$2.95 ,$4.80 ,$2.40 ,$7.20 ,$6.00 ,$6.40 ,$6.64
Hoopeston Regional Hlth Center,9680038,RING SPLINT (OVAL 8),,L3927,274,$28.00 ,$28.00 ,$7.84 ,$25.62 ,$19.60 ,$23.44 ,$25.62 ,$25.62 ,$25.62 ,$10.32 ,$16.80 ,$8.40 ,$25.20 ,$21.00 ,$22.40 ,$23.24
Hoopeston Regional Hlth Center,9680039,DISTAL HUMERUS FX ORTHOSIS,,L3980,274,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9680040,RADIUS/ULNAR FX ORTHOSIS,,L3982,274,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9100118,HRHC SHELL MULTI-FOCAL IOL RESTOR,107791,V2788,276,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,9100128,HRHC IOL STANDARD ACRYSOF IQ 13.0MM X 6.0MM ALCON,79020,V2632,276,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,9100117,HRHC SHELL TORIC IOL ACRYSOF IQ 13.0MM X 6.0MM ALCON,79880,V2787,276,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,9100128,HRHC SHELL BAUSCH & LOMB IOL,79881,V2632,276,$820.00 ,$820.00 ,$229.60 ,$750.30 ,$574.00 ,$686.34 ,$750.30 ,$750.30 ,$750.30 ,$302.17 ,$492.00 ,$246.00 ,$738.00 ,$615.00 ,$656.00 ,$680.60
Hoopeston Regional Hlth Center,7453072,Cautery Essure System,,A4264,278,"$5,850.00 ","$5,850.00 ","$1,638.00 ","$5,352.75 ","$4,095.00 ","$4,896.45 ","$5,352.75 ","$5,352.75 ","$5,352.75 ","$2,155.73 ","$3,510.00 ","$1,755.00 ","$5,265.00 ","$4,387.50 ","$4,680.00 ","$4,855.50 "
Hoopeston Regional Hlth Center,9100155,PLUG HERNIA LG PERLIX,101894,C1781,278,$603.00 ,$603.00 ,$168.84 ,$551.75 ,$422.10 ,$504.71 ,$551.75 ,$551.75 ,$551.75 ,$222.21 ,$361.80 ,$180.90 ,$542.70 ,$452.25 ,$482.40 ,$500.49
Hoopeston Regional Hlth Center,9100155,MESH PLUS MEDIUM PERLIX HERNIA 1.,101895,C1781,278,$820.80 ,$820.80 ,$229.82 ,$751.03 ,$574.56 ,$687.01 ,$751.03 ,$751.03 ,$751.03 ,$302.46 ,$492.48 ,$246.24 ,$738.72 ,$615.60 ,$656.64 ,$681.26
Hoopeston Regional Hlth Center,9100155,PLUG HERNIA SM PERLIX,101896,C1781,278,"$1,260.00 ","$1,260.00 ",$352.80 ,"$1,152.90 ",$882.00 ,"$1,054.62 ","$1,152.90 ","$1,152.90 ","$1,152.90 ",$464.31 ,$756.00 ,$378.00 ,"$1,134.00 ",$945.00 ,"$1,008.00 ","$1,045.80 "
Hoopeston Regional Hlth Center,9100156,CEMENT BN ORTHOSET 40GM RADOPQ ST,11917,,278,"$1,233.00 ","$1,233.00 ",$345.24 ,"$1,128.20 ",$863.10 ,"$1,032.02 ","$1,128.20 ","$1,128.20 ","$1,128.20 ",$454.36 ,$739.80 ,$369.90 ,"$1,109.70 ",$924.75 ,$986.40 ,"$1,023.39 "
Hoopeston Regional Hlth Center,9100155,MESH VENTRIO 8X12,120756,C1781,278,"$2,374.43 ","$2,374.43 ",$664.84 ,"$2,172.60 ","$1,662.10 ","$1,987.40 ","$2,172.60 ","$2,172.60 ","$2,172.60 ",$874.98 ,"$1,424.66 ",$712.33 ,"$2,136.99 ","$1,780.82 ","$1,899.54 ","$1,970.78 "
Hoopeston Regional Hlth Center,9100155,MESH VENTRIO 11X4 use #454368,120757,C1781,278,"$3,506.18 ","$3,506.18 ",$981.73 ,"$3,208.15 ","$2,454.33 ","$2,934.67 ","$3,208.15 ","$3,208.15 ","$3,208.15 ","$1,292.03 ","$2,103.71 ","$1,051.85 ","$3,155.56 ","$2,629.64 ","$2,804.94 ","$2,910.13 "
Hoopeston Regional Hlth Center,9100155,MESH VENTRIO 13.8X17.8,120758,C1781,278,"$4,491.68 ","$4,491.68 ","$1,257.67 ","$4,109.89 ","$3,144.18 ","$3,759.54 ","$4,109.89 ","$4,109.89 ","$4,109.89 ","$1,655.18 ","$2,695.01 ","$1,347.50 ","$4,042.51 ","$3,368.76 ","$3,593.34 ","$3,728.09 "
Hoopeston Regional Hlth Center,9100156,SUTURE ANCHOR BIOSWIVELOCK CLS,131144,,278,"$1,687.50 ","$1,687.50 ",$472.50 ,"$1,544.06 ","$1,181.25 ","$1,412.44 ","$1,544.06 ","$1,544.06 ","$1,544.06 ",$621.84 ,"$1,012.50 ",$506.25 ,"$1,518.75 ","$1,265.63 ","$1,350.00 ","$1,400.63 "
Hoopeston Regional Hlth Center,9100179,HRHC I STENT TRABECULAR MICRO-BYPASS,202735,C1783,278,"$9,112.50 ","$9,112.50 ","$2,551.50 ","$8,337.94 ","$6,378.75 ","$7,627.16 ","$8,337.94 ","$8,337.94 ","$8,337.94 ","$3,357.96 ","$5,467.50 ","$2,733.75 ","$8,201.25 ","$6,834.38 ","$7,290.00 ","$7,563.38 "
Hoopeston Regional Hlth Center,9100155,MESH TVT GYNECARE DEVICE 1/BX,2647,C1781,278,"$5,275.08 ","$5,275.08 ","$1,477.02 ","$4,826.70 ","$3,692.56 ","$4,415.24 ","$4,826.70 ","$4,826.70 ","$4,826.70 ","$1,943.87 ","$3,165.05 ","$1,582.52 ","$4,747.57 ","$3,956.31 ","$4,220.06 ","$4,378.32 "
Hoopeston Regional Hlth Center,9100155,MESH HERNIA PATCH SM VENTRALEX us,3970,C1781,278,"$1,839.60 ","$1,839.60 ",$515.09 ,"$1,683.23 ","$1,287.72 ","$1,539.75 ","$1,683.23 ","$1,683.23 ","$1,683.23 ",$677.89 ,"$1,103.76 ",$551.88 ,"$1,655.64 ","$1,379.70 ","$1,471.68 ","$1,526.87 "
Hoopeston Regional Hlth Center,9100155,MESH HERNIA PATCH MD VENTRALEX us,3971,C1781,278,"$1,991.25 ","$1,991.25 ",$557.55 ,"$1,821.99 ","$1,393.88 ","$1,666.68 ","$1,821.99 ","$1,821.99 ","$1,821.99 ",$733.78 ,"$1,194.75 ",$597.38 ,"$1,792.13 ","$1,493.44 ","$1,593.00 ","$1,652.74 "
Hoopeston Regional Hlth Center,9100155,MESH VENTRALEX HERNIA PATCH LG us,3972,C1781,278,"$2,533.50 ","$2,533.50 ",$709.38 ,"$2,318.15 ","$1,773.45 ","$2,120.54 ","$2,318.15 ","$2,318.15 ","$2,318.15 ",$933.59 ,"$1,520.10 ",$760.05 ,"$2,280.15 ","$1,900.13 ","$2,026.80 ","$2,102.81 "
Hoopeston Regional Hlth Center,9100139,SYSTEM ESSURE STERILIZATION ESS30,4034,,278,"$6,975.00 ","$6,975.00 ","$1,953.00 ","$6,382.13 ","$4,882.50 ","$5,838.08 ","$6,382.13 ","$6,382.13 ","$6,382.13 ","$2,570.29 ","$4,185.00 ","$2,092.50 ","$6,277.50 ","$5,231.25 ","$5,580.00 ","$5,789.25 "
Hoopeston Regional Hlth Center,9100155,MESH PROLENE HERNIA SYSTEM MED,4316,C1781,278,"$2,028.20 ","$2,028.20 ",$567.90 ,"$1,855.80 ","$1,419.74 ","$1,697.60 ","$1,855.80 ","$1,855.80 ","$1,855.80 ",$747.39 ,"$1,216.92 ",$608.46 ,"$1,825.38 ","$1,521.15 ","$1,622.56 ","$1,683.41 "
Hoopeston Regional Hlth Center,9100155,MESH PROLENE HERNIA SYSTEM LG,4317,C1781,278,"$2,946.56 ","$2,946.56 ",$825.04 ,"$2,696.10 ","$2,062.59 ","$2,466.27 ","$2,696.10 ","$2,696.10 ","$2,696.10 ","$1,085.81 ","$1,767.94 ",$883.97 ,"$2,651.90 ","$2,209.92 ","$2,357.25 ","$2,445.64 "
Hoopeston Regional Hlth Center,9100155,MESH PROLENE HERNIA SYSTEM EXT 3/,4318,C1781,278,"$1,101.65 ","$1,101.65 ",$308.46 ,"$1,008.01 ",$771.16 ,$922.08 ,"$1,008.01 ","$1,008.01 ","$1,008.01 ",$405.96 ,$660.99 ,$330.50 ,$991.49 ,$826.24 ,$881.32 ,$914.37
Hoopeston Regional Hlth Center,9100155,MESH PLUG LARGE MARLEX,4319,C1781,278,$598.35 ,$598.35 ,$167.54 ,$547.49 ,$418.85 ,$500.82 ,$547.49 ,$547.49 ,$547.49 ,$220.49 ,$359.01 ,$179.51 ,$538.52 ,$448.76 ,$478.68 ,$496.63
Hoopeston Regional Hlth Center,9100155,MESH SHEET 3X6IN use #454363,4322,C1781,278,$190.50 ,$190.50 ,$53.34 ,$174.31 ,$133.35 ,$159.45 ,$174.31 ,$174.31 ,$174.31 ,$70.20 ,$114.30 ,$57.15 ,$171.45 ,$142.88 ,$152.40 ,$158.12
Hoopeston Regional Hlth Center,9100139,PORT POWER GROSHONG 8FR,64351,,278,"$1,777.50 ","$1,777.50 ",$497.70 ,"$1,626.41 ","$1,244.25 ","$1,487.77 ","$1,626.41 ","$1,626.41 ","$1,626.41 ",$655.01 ,"$1,066.50 ",$533.25 ,"$1,599.75 ","$1,333.13 ","$1,422.00 ","$1,475.33 "
Hoopeston Regional Hlth Center,9100139,PIN ORTHOSORB RESORB 1.3,64361,,278,$759.51 ,$759.51 ,$212.66 ,$694.95 ,$531.66 ,$635.71 ,$694.95 ,$694.95 ,$694.95 ,$279.88 ,$455.71 ,$227.85 ,$683.56 ,$569.63 ,$607.61 ,$630.39
Hoopeston Regional Hlth Center,9100139,PIN ORTHOSORB RESORB 40X2.0,64362,,278,$823.53 ,$823.53 ,$230.59 ,$753.53 ,$576.47 ,$689.29 ,$753.53 ,$753.53 ,$753.53 ,$303.47 ,$494.12 ,$247.06 ,$741.18 ,$617.65 ,$658.82 ,$683.53
Hoopeston Regional Hlth Center,9100155,PLUG HERNIA MEDIUM Use # 622068,64386,C1781,278,$685.58 ,$685.58 ,$191.96 ,$627.31 ,$479.91 ,$573.83 ,$627.31 ,$627.31 ,$627.31 ,$252.64 ,$411.35 ,$205.67 ,$617.02 ,$514.19 ,$548.46 ,$569.03
Hoopeston Regional Hlth Center,9100139,RING CAPSULAR TENSION TYPE 14C,64396,,278,$805.50 ,$805.50 ,$225.54 ,$737.03 ,$563.85 ,$674.20 ,$737.03 ,$737.03 ,$737.03 ,$296.83 ,$483.30 ,$241.65 ,$724.95 ,$604.13 ,$644.40 ,$668.57
Hoopeston Regional Hlth Center,9100139,ANCHOR T KUMAR HERNIA SET,64397,,278,$211.50 ,$211.50 ,$59.22 ,$193.52 ,$148.05 ,$177.03 ,$193.52 ,$193.52 ,$193.52 ,$77.94 ,$126.90 ,$63.45 ,$190.35 ,$158.63 ,$169.20 ,$175.55
Hoopeston Regional Hlth Center,9650041,OXYGEN CONCENTRATOR,,,291,$750.00 ,$750.00 ,$210.00 ,$686.25 ,$525.00 ,$627.75 ,$686.25 ,$686.25 ,$686.25 ,$276.38 ,$450.00 ,$225.00 ,$675.00 ,$562.50 ,$600.00 ,$622.50
Hoopeston Regional Hlth Center,8980294,racepinephrine 2.25 % solution for nebulization,487590199,J7699,294,$10.72 ,$10.72 ,$3.00 ,$9.81 ,$7.50 ,$8.97 ,$9.81 ,$9.81 ,$9.81 ,$3.95 ,$6.43 ,$3.22 ,$9.65 ,$8.04 ,$8.58 ,$8.90
Hoopeston Regional Hlth Center,9881002,URINE DIPSTICK,,81002,300,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9882272,HEMOCULT,,82272,300,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9082272,HEMOCULT,,82272,300,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9399006,HOME VENI PUNCTURE,,36415,300,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9399008,VENIPUNCTURE FOR LAB SPECIMEN,,36415,300,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9399018,VENIPUNCTURE FOR LAB SPECIMEN,,36415,300,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9380051,ELECTROLYTE PANEL,,80051,300,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9383703,LIPID PROFILE,,80061,300,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9380069,RENAL FUNCTION PANEL,,80069,300,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9380058,HEPATIC FUNCTION PANEL,,80076,300,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9382641,DRUG ASSAY -DIGOXIN,,80162,300,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9380170,DRUG ASSAY -GENTAMYCIN,,80170,300,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9380173,DRUG ASSAY -HALOPERIDOL REF,,80173,300,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,9383725,DRUG ASSAY -LITHIUM,,80178,300,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9384142,DRUG ASSAY -PROCAINAMIDE +,,80192,300,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9384420,DRUG ASSAY -THEOPHYLLINE,,80198,300,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9380200,DRUG ASSAY -TOBRAMYCIN,,80200,300,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9380202,DRUG ASSAY -VANCOMYCIN,,80202,300,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9380604,"MYCOPHENOLIC ACID, S REF",,80180,300,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9381000,URINALYSIS AUTO W/MICROSCOPY,,81001,300,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9381001,URINALYSIS -GLUCOSE,,81002,300,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9381003,CLINITEST,,81002,300,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9381009,URINALYSIS -SPECIFIC GRAVITY,,81002,300,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9381010,LEUKOCYTE ESTERASE FLD,,81002,300,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9381004,URINALYSIS AUTO W/O MICROSCOPY,,81003,300,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9381002,URINALYSIS -MICROSCOPIC ONLY,,81015,300,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9383160,URINE PREGNANCY TEST,,81025,300,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9381050,VOL MEASURE -TIMED COLLCTN EA,,81050,300,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382015,"ACETYLCHOLINESTERASE, AF REF",,82013,300,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9382270,OCCULT BLOOD,,82270,300,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382311,"CALCIUM, IONIZED",,82330,300,$98.00 ,$98.00 ,$27.44 ,$89.67 ,$68.60 ,$82.03 ,$89.67 ,$89.67 ,$89.67 ,$36.11 ,$58.80 ,$29.40 ,$88.20 ,$73.50 ,$78.40 ,$81.34
Hoopeston Regional Hlth Center,9382373,CARB DEFICIENT TRANSFERRIN REF,,82373,300,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382391,CERULOPLASMIN,,82390,300,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9382435,"CHLORIDE, BLOOD",,82435,300,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382438,"CHLORIDE, STOOL",,82438,300,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9382443,"CHOLESTEROL, SERUM, TOTAL REF",,82465,300,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9382465,"CHOLESTEROL, SERUM, TOTAL",,82465,300,$82.00 ,$82.00 ,$22.96 ,$75.03 ,$57.40 ,$68.63 ,$75.03 ,$75.03 ,$75.03 ,$30.22 ,$49.20 ,$24.60 ,$73.80 ,$61.50 ,$65.60 ,$68.06
Hoopeston Regional Hlth Center,9382485,CHONDROITIN SULFATE REF,,82485,300,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9382552,CK MB FRACTION,,82553,300,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9382565,"CREATININE, BLOOD",,82565,300,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9382575,CREATININE CLEARANCE,,82575,300,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9382705,FECAL FAT/LIPIDS QUALTATVE REF,,82705,300,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9382731,FETAL FIBRONECTIN,,82731,300,$650.00 ,$650.00 ,$182.00 ,$594.75 ,$455.00 ,$544.05 ,$594.75 ,$594.75 ,$594.75 ,$239.53 ,$390.00 ,$195.00 ,$585.00 ,$487.50 ,$520.00 ,$539.50
Hoopeston Regional Hlth Center,9382950,"GLUCOSE, POST GLUCOSE DOSE",,82950,300,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9382953,"GTT, THREE SPECIMENS",,82951,300,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9382954,"GTT, EA ADDL BEYOND THREE",,82952,300,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9382977,"GLUTAMYLTRANSFERASE, GAMMA",,82977,300,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9383010,"HAPTOGLOBIN, QUANTITATIVE",,83010,300,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9385003,APT TEST FOR FETAL HGB,,83033,300,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9380602,"IRON, LIVER TISSUE",,83540,300,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9383540,IRON,,83540,300,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9383550,IRON BINDING CAPACITY,,83550,300,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9383690,LIPASE,,83690,300,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9383864,MUCOPOLYSACCHAR QT REF,,83864,300,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9383873,"MYELIN BASIC PROTEIN, CSF REF",,83873,300,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383650,ASSAY OF MYOGLOBIN REF,,83874,300,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381006,:MYOGLOBIN,,83874,300,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9383916,OLIGOCLONAL BANDS,,83916,300,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9383930,"OSMOLALITY, BLOOD",,83930,300,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9383305,PARATHYROID HORMONE C-TRM REF,,83970,300,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9383970,"PARATHYROID HORMONE,INTACT REF",,83970,300,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9380127,PARATHORMONE (PTH),,83970,300,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9384030,"PHENYLALANINE (PKU), BLOOD REF",,84030,300,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9384123,"PORPHYRINS FRACT, URINE REF",,84120,300,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9384140,"POTASSIUM, SERUM",,84132,300,$82.00 ,$82.00 ,$22.96 ,$75.03 ,$57.40 ,$68.63 ,$75.03 ,$75.03 ,$75.03 ,$30.22 ,$49.20 ,$24.60 ,$73.80 ,$61.50 ,$65.60 ,$68.06
Hoopeston Regional Hlth Center,9382940,PREALBUMIN,,84134,300,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9384165,PROTEIN ELP FRACT&QUANT SERUM,,84165,300,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9384210,PYRUVIC ACID REF,,84210,300,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9384220,PYRUVATE KINASE REF,,84220,300,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,9384295,SODIUM SERUM PLASM/WHOLE BLOOD,,84295,300,$80.00 ,$80.00 ,$22.40 ,$73.20 ,$56.00 ,$66.96 ,$73.20 ,$73.20 ,$73.20 ,$29.48 ,$48.00 ,$24.00 ,$72.00 ,$60.00 ,$64.00 ,$66.40
Hoopeston Regional Hlth Center,9383632,"INSULIN-LIKE GROWTH FACTOR 1, S REF",,84305,300,$85.00 ,$85.00 ,$23.80 ,$77.78 ,$59.50 ,$71.15 ,$77.78 ,$77.78 ,$77.78 ,$31.32 ,$51.00 ,$25.50 ,$76.50 ,$63.75 ,$68.00 ,$70.55
Hoopeston Regional Hlth Center,9384316,"SPECIFIC GRAVITY, BODY FLUID",,84315,300,$84.00 ,$84.00 ,$23.52 ,$76.86 ,$58.80 ,$70.31 ,$76.86 ,$76.86 ,$76.86 ,$30.95 ,$50.40 ,$25.20 ,$75.60 ,$63.00 ,$67.20 ,$69.72
Hoopeston Regional Hlth Center,9384450,"TRANSFERASE, ASPARTATE AMINO",,84450,300,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9386340,TRANSFERRIN,,84466,300,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9380223,"TRIIODOTHYRONINE T3, TOTAL REF",,84480,300,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9383439,"TRIIODOTHYRONINE T3, TOTAL",,84480,300,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9380215,"TROPONIN, QUANTITATIVE REF",,84484,300,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9384484,"TROPONIN, QUANTITATIVE",,84484,300,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9384510,ASSAY OF TYROSINE REF,,84510,300,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9384520,"UREA NITROGEN, QUANTITATIVE",,84520,300,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9384521,BUN BODY FLUID,,84520,300,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9384550,"URIC ACID, BLOOD",,84550,300,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9385000,BLEEDING TIME,,85002,300,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9385641,"RETICULOCYTE COUNT, AUTOMATED",,85045,300,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9385311,PROTEIN C PLASMA ANTIGEN REF,,85302,300,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9385363,PROTEIN S TOTAL REF,,85305,300,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9385150,PROTEIN S FREE REF,,85306,300,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9385306,PROTEIN S ANTIGEN FREE,,85306,300,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9386149,ACTIVATED PROTEIN C RESISTANCE,,85307,300,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,9385362,FIBRIN DEGREDATION PRODUCTS,,85362,300,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9385545,KLEIHAUER-BETKE TEST,,85460,300,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9385460,"FMH SCREEN, ROSETTE",,85461,300,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9385635,REPTILASE TEST (VENOM TIME),,85635,300,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9385651,ESR WESTERGREN,,85652,300,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9385670,THROMBIN TIME,,85670,300,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9385720,"THROMBOPLSTN TIME,PTL(PTT) REF",,85730,300,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9385730,"THROMBOPLASTIN TIME, PTL (PTT)",,85730,300,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9385732,CORRECTION STUDIES,,85732,300,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9385810,"VISCOSITY, SERUM REF",,85810,300,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9382929,AB ID; PLT IMMGLB ASY REF,,86023,300,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9380614,"HE 4, OVARIAN CANCER MNTR REF",,86305,300,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9386300,MONO TEST,,86308,300,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9386418,LABORATORY TEST REF,,86592,300,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9386415,LABORATORY TEST,,86592,300,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,9386416,LABORATORY TEST,,86593,300,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9386305,LABORATORY TEST FOR ANTIBODY,,86701,300,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,9386049,LABORATORY TEST,,G0432,300,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9386294,HEPATITIS B CORE IGM ANTIBODY,,86705,300,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9386706,HEPATITIS B SURFACE AB REF,,86706,300,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9386307,HEPATITIS B SURFACE ANTIBODY,,86706,300,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9386762,RUBELLA IGG AB BY EIA REF,,86762,300,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386763,RUBELLA IGM TITER REF,,86762,300,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386435,RUBELLA IGG SCREEN,,86762,300,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9383803,HEPATITIS BC AB REF,,86803,300,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9386803,HEPATITIS C AB REF,,86803,300,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9386281,HEPATITIS C VIRUS ANTIBODY,,86803,300,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9386312,HCV CONFIRMATION BY SIA REF,,86804,300,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9386025,"INDIRECT, TITER",,86886,300,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9386900,BLOOD TYPING; ABO REF,,86900,300,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9386080,"BLOOD TYPING, ABO",,86900,300,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9386901,BLOOD TYPING; RH(D) REF,,86901,300,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9386100,"BLOOD TYPING, RH",,86901,300,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386902,ANTIGEN TYPING EA ANTIGEN TEST,,86902,300,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9386903,ANTIGEN TYPING,,86902,300,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,9386905,BLOOD TYPNG RBC AG N ABO/RH RF,,86905,300,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9386019,ANTIGEN TYPING,,86905,300,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9386920,COMPATIBILITY IMMEDIATE SPIN,,86920,300,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,9380219,COMPATABILITY AHG REF,,86922,300,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9386922,COMPATABILITY AHG,,86922,300,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,9386203,FROZEN PLASMA PREP,,86927,300,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9386945,IRRAD. BLOOD PROD. CCB REF,,86945,300,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,9386965,PLTLTS/BLOOD PRODUCT POOLING,,86965,300,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9386970,"PRETREAT RBCS W/CHEMICAL, EA PNL REF",,86970,300,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,9386971,"PRETREAT RBCS W/ENZYMES, EA PNL REF",,86971,300,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,9386985,SPLITTING OF BLOOD/BLOOD PRDCT,,86985,300,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9386101,BONE BANK PROCESSING,,86999,300,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,9386987,L-P PLT FILTER,,86999,300,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9388006,DIRECTED DONOR CONSULT,,86999,300,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9387040,"BACTERIAL CULTURE, BLOOD",,87040,300,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9387050,BLOOD CULTURE,,87040,300,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9387095,ENTERIC PATHOGENS CULTURE,,87045,300,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9387046,ENT PATH CULT / ADNL PATHOGENS,,87046,300,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9387075,BACT CULT ANY SRC ANAEROBIC,,87075,300,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9387110,URINE CULTURE,,87086,300,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9387002,URINE CULTURE PRESUMPTIVE ID,,87088,300,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9387098,"FUNGUS CULT, DERMAL",,87101,300,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9387102,"FUNGAL CULT, OTHER SRC, ISOLAT",,87102,300,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,9387105,"FUNGAL CULTURE, ENVIRONMENTAL",,87102,300,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9387103,"FUNGAL CULTURE, BLOOD",,87103,300,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9387145,CULTURE REF,,87110,300,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9387116,"CULT, TUBRCL/ACID-FAST BACILLI",,87116,300,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9387118,AFB ISOLATE IDENTIFICATION,,87118,300,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9387169,"MACROSCOPIC EXAM, PARASITE",,87169,300,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9387171,HOMOGENIZATN TISSUE FR CULTURE,,87176,300,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9387187,SERUM BACTERICIDAL TITER,,87197,300,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9387205,"SMEAR, PRIMARY SRCE RTN STAIN",,87205,300,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,9387206,"SMEAR, PRIMARY SRC FLRSNT/AF",,87206,300,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9387212,"WET MOUNT, PRIMARY SOURCE",,87210,300,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9387299,INF AGNT NOS EA REF,,87299,300,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9387340,HBSAG CONFRM BY IMMUNOASSY REF,,87340,300,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9386287,HEPATITIS B SURFACE ANTIGEN,,87340,300,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9387380,HEP D VIRUS AG REF,,87380,300,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9387425,ROTOVIRUS ANTIGEN,,87425,300,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9387491,LABORATORY TEST,,87491,300,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9387591,LABORATORY TEST,,87591,300,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9387880,"STREPTOCOCCUS, GROUP A",,87880,300,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9387997,MICROSCOPIC EXAM,,87999,300,$70.00 ,$70.00 ,$19.60 ,$64.05 ,$49.00 ,$58.59 ,$64.05 ,$64.05 ,$64.05 ,$25.80 ,$42.00 ,$21.00 ,$63.00 ,$52.50 ,$56.00 ,$58.10
Hoopeston Regional Hlth Center,9389053,CELL CT & DIFF MISC FLUID REF,,89051,300,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9389051,"CELL CT & DIFF, MISC. FLUID",,89051,300,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9389125,SPECIMEN FAT STAIN REF,,89125,300,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9389190,NASAL SMEAR EOS,,89190,300,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9389802,PROCESSING AND HANDLING,,99001,300,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9399001,CLINICAL TRIAL PROCESSING (INPT),,99001,300,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9380337,FECAL BACTERIOTHERAPY,,99199,300,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9381446,CRYSTALS (U) REF,,81015,300,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9380227,KETONE-URINE,,81000,300,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9380228,KETONE-SERUM,,82009,300,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9386705,HEPATITIS B CORE IGM ANTIBODY REF,,86705,300,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9300006,CBC W/AUTOMATED DIFFERENTIAL,,85025,300,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9300007,HEPATITIS B SURFACE ANTIGEN,,87340,300,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9300008,RUBELLA IGG SCREEN,,86762,300,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9300009,LABORATORY TEST,,86592,300,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9300010,ANTIBODY SCREENING,,86850,300,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9300011,"BLOOD TYPING, ABO",,86900,300,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9300012,"BLOOD TYPING, RH",,86901,300,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9381505,"HEPTOGLOBIN, QUANTIATIVE REF",,83010,300,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9381507,"GLUTAMYLTRANSFERASE, GAMMA REF",,82977,300,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9381480,RETICULOCYTE/SICKLE CELL SEP REF,,86972,300,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9381483,SPR ANTIGEN TYPE-TIER REF,,86902,300,$25.00 ,$25.00 ,$7.00 ,$22.88 ,$17.50 ,$20.93 ,$22.88 ,$22.88 ,$22.88 ,$9.21 ,$15.00 ,$7.50 ,$22.50 ,$18.75 ,$20.00 ,$20.75
Hoopeston Regional Hlth Center,9381489,ESR (PHOTOMETRIC),,85652,300,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381492,"HOMOGENIZATION, TISSUE, FOR CULTURE REF",,87176,300,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9381494,DRUG SCREEN QUANT CLOSAPINE REF,,80159,300,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9380255,"ALCOHOL EMPLOYMENT, BREATH",,82075,300,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9380253,COLLECTION OF DOT DRUG SCREEN,,99001,300,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9380254,COLLECTION OF COC DRUG SCREEN,,99001,300,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,8281025,URINE PREGNANCY,,81025,300,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9380284,LABORATORY TEST REF,,87491,300,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380285,LABORATRY TEST REF,,87591,300,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380286,"WET MOUNT, INFECTIOUS AGENT REF",,87210,300,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9381520,"CALCIUM, IONIZED, S REF",,82330,300,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9381532,BACT CULT ANY SRC ANAEROBIC REF,,87075,300,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,9300002,CMP PANEL,,80053,300,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9300003,CBC W/AUTO DIFF,,85025,300,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9300004,TSH,,84443,300,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9381545,PROTHROMBIN TIME-SUBSTITUTION/IMMED,,85611,300,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381547,PROTHROMBIN TIME-SUBSTITUTION/INCUBATED,,85611,300,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381548,"THROMBOPLASTIN TIME, PTL (PTT)-SUBSTITUTION/IMMED",,85732,300,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9381549,"THROMBOPLASTIN TIME, PTL (PTT)-INCUBATED",,85730,300,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,9381553,LITHIUM REF,,80178,300,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9380636,"PREALBUMIN (PAB), SERUM REF",,84134,300,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9381561,"GLUTATHIONE, B REF",,82978,300,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9381567,"RUBELLA AB, IGG (TRCHG) REF",,86762,300,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9381573,"LD, LDH REF",,84550,300,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9381574,LIPASE REF,,83690,300,$28.00 ,$28.00 ,$7.84 ,$25.62 ,$19.60 ,$23.44 ,$25.62 ,$25.62 ,$25.62 ,$10.32 ,$16.80 ,$8.40 ,$25.20 ,$21.00 ,$22.40 ,$23.24
Hoopeston Regional Hlth Center,9381576,MYCOBACTERIAL CULTURE REF,,87116,300,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9381585,"ACTIVATED PROTEIN RESISTANCE V, P REF",,85307,300,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9336416,CAPILLARY SPECIMEN COLLECTION,,36416,300,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9381596,PROTEIN ELECTROPHORESIS REF,,84165,300,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9381624,ELECTROLYTE REF,,80051,300,$28.00 ,$28.00 ,$7.84 ,$25.62 ,$19.60 ,$23.44 ,$25.62 ,$25.62 ,$25.62 ,$10.32 ,$16.80 ,$8.40 ,$25.20 ,$21.00 ,$22.40 ,$23.24
Hoopeston Regional Hlth Center,9381625,"SWEAT COLLECTION, IOTOPHORESIS REF",,89230,300,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,8281003,"URINALYSIS, AUTO, W/O SCOPE",,81003,300,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381639,LABORATORY TEST REF,,86593,300,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9381640,PROTHROMBIN TIME-SUBSTITUTION/IMMED,,85611,300,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9809612,CATH URINE SPECIMEN COLLECTION,,P9612,300,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9381654,"SPERM ANTIBODY (IGA, IGG), REF",,89325,300,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9381675,"ACID FAST SMEAR, REF",,87206,300,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9381696,CRYO QC FOR MRV BLOOD CENTER,,99001,300,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9381770,"REPTILASE TIME, P, REF",,85635,300,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9380997,GRAM STAIN REF,,87205,300,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9381016,SOLUBLE FIBRIN MONOMER REF,,85366,300,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9381032,"CHLORIDE, OTHER SOURCE",,82438,300,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381067,METHOTREXATE REF,,83520,300,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381056,"EVEROLIMUS, B REF",,80169,300,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9381090,CHLORIDE REF,,82435,300,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9381088,"POTASSIUM, PLASMA REF",,84132,300,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381089,SODIUM REF,,84295,300,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381117,"THROMBIN TIME (BOVINE), P REF",,85670,300,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,8081025,BEDSIDE URINE PREGNANCY,,81025,300,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,8081002,BEDSIDE URINE TEST STRIP,,81002,300,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,8082930,OCCULT BLOOD & PH - GASTRIC,,82930,300,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9381119,LABORATORY SERVICES,,86701,300,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9381802,"HE4, S, REF",,86305,300,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9381134,"CREATININE, S REF",,82565,300,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381136,"LEPTOSPIRA STAIN, REF",,87206,300,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9381139,"PORPHYRINS, FECES REF",,84126,300,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9381835,"FUNGAL CULTURE, ROUTINE, REF",,87102,300,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,9381840,"APTT MIX 1:1, REF",,85732,300,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9381832,HIV-1 ANTIBODY,,86701,300,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9381877,"OSMOLALITY SERUM, REF",,83930,300,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9381878,"VDRL, SERUM, REF",,86592,300,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9381902,"FIBRINOGEN ANTIGEN, P, REF",,85385,300,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9381914,"OSMOLALITY, SERUM, REF",,83930,300,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9381944,"ASSAY OF VANCOMYCIN, REF",,80202,300,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9381943,"PT MIX 1:1, REF",,85611,300,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9381995,"LIPID CASCADE, REF",,80061,300,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9382358,"Hc Mono Screen, Ref",,86308,300,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382359,"Hc Syphilis Ab. Casc, Ref",,86592,300,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9382437,"RHEUMATOID FACTORS IGA, IGG, IGM, REF",,84450,300,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382434,TRANSFERASE (AST) (SGOT) REF,,84450,300,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382442,"SED RATE BY MOD WESTERGREN, REF",,85652,300,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,9382413,CERULOPLASMIN REF,,82390,300,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9382457,"CREATININE CLEARANCE, 24 HR REF",,82575,300,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,9382497,"T3 TOTAL, S REF",,84480,300,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9382681,"LIVER FIBROSIS, EER FIBROMETER, REF",,82977,300,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9382673,"LIVER FIBROSIS, CIRRHOMETER, REF",,84450,300,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382549,"VISCOSITY, S [REF]",,85810,300,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9382813,"CLOZAPINE, B [REF]",,80159,300,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9382866,"SMEAR, FLUORESCENT AND/OR ACID FAST STAIN",,87206,300,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9382867,TISSUE PROCESSING,,87176,300,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9382869,MYCOBACTERIA CULTURE,,87116,300,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9382871,"ID BY MALDI-TOF MASS SPEC, AFB",,87118,300,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9382876,TISSUE PROCESSING,,87176,300,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9382973,CK-MB (CK-2) REF,,82553,300,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9382974,"TOBRAMYCIN, TROUGH, REF",,80200,300,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9383144,"PORPHYRINS, FECES, REF",,84126,300,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9383162,"FIBRINOGEN DEGRADATION PRODUCTS (FDP), REF",,85362,300,$28.00 ,$28.00 ,$7.84 ,$25.62 ,$19.60 ,$23.44 ,$25.62 ,$25.62 ,$25.62 ,$10.32 ,$16.80 ,$8.40 ,$25.20 ,$21.00 ,$22.40 ,$23.24
Hoopeston Regional Hlth Center,9383175,"RH PHENOTYPING, REF",,86906,300,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,8286308,MONO TEST,,86308,300,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,36415,"COLLECTION VENOUS BLOOD,VENIPUNCTURE",,36415,300,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,81002,URINALYSIS NONAUTO W/O SCOPE,,81002,300,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,81003,"URINALYSIS, AUTO, W/O SCOPE",,81003,300,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,81025,URINE PREGNANCY TEST,,81025,300,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,82270,"BLOOD OCCULT,BY PEROXID,FECES,SINGLE, COLORECTAL SCREEN",,82270,300,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,82962,GLUCOSE BLOOD TEST,,82962,300,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,85610,PROTHROMBIN TIME,,85610,300,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,Q0114,Fern test,,Q0114,300,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,87804,"DETECT AGENT,IMMUN,DIR OBS,INFLUENZA",,87804,300,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,87807,"DETECT AGENT,IMMUN,DIR OBS, RSV",,87807,300,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,87502,INFECTIOUS AGENT DNA/RNA INFLUENZA 1ST 2 TYPES,,87502,300,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9384112,AMNISURE ROM,,84112,301,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9381362,MED TOX 11 DRUG SCREEN,,80305,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9381363,"DRUG SCREEN, SNGL CLASS LIST A; INST IA OR EIA SYSTEM, PER DOS",,80307,301,$98.00 ,$98.00 ,$27.44 ,$89.67 ,$68.60 ,$82.03 ,$89.67 ,$89.67 ,$89.67 ,$36.11 ,$58.80 ,$29.40 ,$88.20 ,$73.50 ,$78.40 ,$81.34
Hoopeston Regional Hlth Center,9381364,"DRUG SCREEN, MULT CLASSES LIST A; NON-TLC DEVICE, PER DOS",,80305,301,$98.00 ,$98.00 ,$27.44 ,$89.67 ,$68.60 ,$82.03 ,$89.67 ,$89.67 ,$89.67 ,$36.11 ,$58.80 ,$29.40 ,$88.20 ,$73.50 ,$78.40 ,$81.34
Hoopeston Regional Hlth Center,9381365,SALICYLATE,,80307,301,$98.00 ,$98.00 ,$27.44 ,$89.67 ,$68.60 ,$82.03 ,$89.67 ,$89.67 ,$89.67 ,$36.11 ,$58.80 ,$29.40 ,$88.20 ,$73.50 ,$78.40 ,$81.34
Hoopeston Regional Hlth Center,9381366,ACETAMINOPHEN,,80307,301,$98.00 ,$98.00 ,$27.44 ,$89.67 ,$68.60 ,$82.03 ,$89.67 ,$89.67 ,$89.67 ,$36.11 ,$58.80 ,$29.40 ,$88.20 ,$73.50 ,$78.40 ,$81.34
Hoopeston Regional Hlth Center,9381271,ALCOHOL BIOMARKERS; 1 OR 2 REF,,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381272,ALCOHOL BIOMARKERS; 3 OR MORE REF,,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381273,"ALKALOIDS, NOS REF",,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381274,AMPHETAMINES; 1 OR 2 REF,,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381276,AMPHETAMINES; 3 OR 4 REF,,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381277,AMPHETAMINES; 5 OR MORE REF,,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381284,"ANTIDEPRESSANTS, SEROTONERGIC CLASS; 1 OR 2 REF",,80332,301,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9381288,"ANTIDEPRESSANTS, TRICYCLIC, OTHER CYCLICALS; 3-5 REF",,80336,301,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9381289,"ANTIDEPRESSANTS, TRICYCLIC, OTHER CYCLICALS; 6 OR MORE REF",,80337,301,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381305,"ANTIDEPRESSANTS, NOS REF",,80338,301,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9381306,"ANTIEPILEPTICS, NOS; 1-3 REF",,80339,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381307,"ANTIEPILEPTICS, NOS; 4-7 REF",,80340,301,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9381308,"ANTIEPILEPTICS, NOS; 7 OR MORE REF",,80341,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9381309,"ANTIPSYCHOTICS, NOS; 1-3 REF",,80342,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9381311,"ANTIPSYCHOTICS, NOS; 4-6 REF",,80343,301,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9381312,"ANTIPSYCHOTICS, NOS; 7 OR MORE REF",,80344,301,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9381313,BARBITURATES REF,,80345,301,$44.00 ,$44.00 ,$12.32 ,$40.26 ,$30.80 ,$36.83 ,$40.26 ,$40.26 ,$40.26 ,$16.21 ,$26.40 ,$13.20 ,$39.60 ,$33.00 ,$35.20 ,$36.52
Hoopeston Regional Hlth Center,9381314,BENZODIAZEPINES; 1-12 REF,,80346,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9381316,BENZODIAZEPINES; 13 OR MORE REF,,80347,301,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9381320,BUPRENORPHINE REF,,80348,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9381327,"CANNABINOIDS, NATURAL REF",,80349,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9381328,"CANNABINOIDS, SYNTHETIC; 1-3 REF",,80350,301,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9381329,"CANNABINOIDS, SYNTHETIC; 4-6 REF",,80351,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9381333,"CANNABINOIDS, SYNTHETIC; 7 OR MORE REF",,80352,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9381334,COCAINE REF,,80353,301,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9381335,FENTANYL REF,,80354,301,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381336,"GABAPENTIN, NON-BLOOD REF",,80355,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9381337,HEROINE METABOLITE REF,,80356,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9381338,KETAMINE AND NON-KETAMINE REF,,80357,301,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9381339,METHADONE REF,,80358,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381341,"METHYLENEDIOXYAMPHETAMINES (MDA, MDEA, MDMA) REF",,80359,301,$40.00 ,$40.00 ,$11.20 ,$36.60 ,$28.00 ,$33.48 ,$36.60 ,$36.60 ,$36.60 ,$14.74 ,$24.00 ,$12.00 ,$36.00 ,$30.00 ,$32.00 ,$33.20
Hoopeston Regional Hlth Center,9381343,METHYLPHENIDATE REF,,80360,301,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9381344,"OPIATES, 1 OR MORE REF",,80361,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9381345,OPIOIDS AND OPIATE ANALOGS; 1 OR 2 REF,,80362,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9381346,OPIOIDS AND OPIATE ANALOGS; 3 OR 4 REF,,80363,301,$85.00 ,$85.00 ,$23.80 ,$77.78 ,$59.50 ,$71.15 ,$77.78 ,$77.78 ,$77.78 ,$31.32 ,$51.00 ,$25.50 ,$76.50 ,$63.75 ,$68.00 ,$70.55
Hoopeston Regional Hlth Center,9381347,OPIOIDS AND OPIATE ANALOGS; 5 OR MORE REF,,80364,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9381348,OXYCODONE REF,,80365,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9381349,PREGABALIN REF,,80366,301,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9381351,PROPOXYPHENE REF,,80367,301,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9381352,SEDATIVE HYPNOTICS (NON-BENZODIAZEPINES) REF,,80368,301,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9381353,SKELETAL MUSCLE RELAXANTS; 1 OR 2 REF,,80369,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9381354,SKELETAL MUSCLE RELAXANTS; 3 OR MORE REF,,80370,301,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9381355,"STIMULANTS, SYNTHETIC REF",,80371,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9381356,TAPENTADOL REF,,80372,301,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9381357,TRAMADOL REF,,80373,301,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9381358,"STEREOISOMER (ENANTIOMER) ANLY, SNGL DRUG CLASS REF",,80374,301,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9381359,"DRUGS, SUBSTANCES, DEFIN, QL OR QNT, NOS; 1-3 REF",,80375,301,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9381360,"DRUGS, SUBSTANCES, DEFIN, QL OR QNT, NOS; 4-6 REF",,80376,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9381361,"DRUGS, SUBSTANCES, DEFIN, QL OR QNT, NOS; 7 OR MORE REF",,80377,301,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9381367,DOT DRUG SCREEN (DEPT OF TRANSPORTATION) REF,,80305,301,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9381368,COC DRUG SCREEN (CHAIN OF CUSTODY) REF,,80305,301,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9381369,K2 SPICE DRUG SCREEN REF,,80306,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381370,BATH SALTS DRUG SCREEN REF,,80306,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381371,CPT-CORDSTAT 13 DRUG PANEL REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381377,CPT-CORDSTAT 13 DRUG PANEL REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381378,CPT-CORDSTAT 13 DRUG+ETOH PANEL REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381379,CPT-CORDSTAT 13 DRUG+ETOH PANEL REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381383,CORDSTAT ETOH REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381385,CPT-LACTOSTAT 13 DRUG PANEL REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381386,CPT-MECSTAT 13 DRUG PANEL REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381387,CPT-MECSTAT 13 DRUG PANEL REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381388,CPT-MECSTAT 13 DRUG+ETOH PANEL REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381389,CPT-MECSTAT 13 DRUG+ETOH PANEL REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381390,CPT-MECSTAT ETOH REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381391,"BENZODIAZEPINES CONFIRM, U REF REF",,80346,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9381392,"CLONAZEPAM, S REF",,80346,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9381393,"DOXEPIN AND NORDOXEPIN, S REF",,80335,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381394,"AMITRIPTYLINE AND NORTRIPTYLINE, S REF",,80335,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381395,"NORTRIPTYLINE, S REF",,80335,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381396,PENTOBARBITAL REF,,80345,301,$44.00 ,$44.00 ,$12.32 ,$40.26 ,$30.80 ,$36.83 ,$40.26 ,$40.26 ,$40.26 ,$16.21 ,$26.40 ,$13.20 ,$39.60 ,$33.00 ,$35.20 ,$36.52
Hoopeston Regional Hlth Center,9381397,"DIHYDROTESTOSTERONE, S REF",,80327,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9381398,"NICOTINE AND METABOLITES, S REF",,80323,301,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9381399,"NICOTINE AND METABOLITES, U REF",,80323,301,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9381430,"HEARING LOSS; SEQ ANALY, 60 OR MORE GENES REF",,81430,301,"$6,500.00 ","$6,500.00 ","$1,820.00 ","$5,947.50 ","$4,550.00 ","$5,440.50 ","$5,947.50 ","$5,947.50 ","$5,947.50 ","$2,395.25 ","$3,900.00 ","$1,950.00 ","$5,850.00 ","$4,875.00 ","$5,200.00 ","$5,395.00 "
Hoopeston Regional Hlth Center,9381431,"HEARING LOSS; DUP/DEP, 8 OR MORE GENES REF",,81431,301,"$2,720.00 ","$2,720.00 ",$761.60 ,"$2,488.80 ","$1,904.00 ","$2,276.64 ","$2,488.80 ","$2,488.80 ","$2,488.80 ","$1,002.32 ","$1,632.00 ",$816.00 ,"$2,448.00 ","$2,040.00 ","$2,176.00 ","$2,257.60 "
Hoopeston Regional Hlth Center,9383992,PHENCYCLIDINE (PCP) REF,,83992,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9381425,"CPT-TSTTF TESTOS TOTAL, FREE REF",,84403,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9381426,"CPT-TTTBF TESTOS TOTAL, BIO, FREE REF",,84403,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9381409,"VALPROIC ACID, FREE, S REF",,80165,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9381410,"COBALT, S REF",,83018,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9381424,MUSK ANTIBODY REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381412,GALACTOSE REF,,82760,301,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9381413,LACTATE (LACTIC ACID) REF,,83605,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381414,"PREGNENOLONE, S REF",,84140,301,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9381415,RECEPTOR ASSAY; NON-ENDOCRINE REF,,84238,301,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9381416,TRIGLYCERIDES REF,,84478,301,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9381427,EPIANDROSTERONE REF,,80327,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9381428,DESIPRAMINE REF,,80335,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381429,IMIPRAMINE REF,,80335,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381432,DIMETHADIONE REF,,80339,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381433,METHSUXIMIDE REF,,80339,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381434,PHENOTHIAZINE REF,,80344,301,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9381435,DIHYDROCODEINONE REF,,80361,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9381436,DIHYDROMORPHINONE REF,,80361,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9381437,"OPIATES, DRUG AND METAB, EA REF",,80361,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9381438,MEPROBAMATE REF,,80369,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9381440,"THYROXINE, TOTAL REF",,84436,301,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381441,THYROXINE BINDING CAPACITY REF,,84479,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9380049,BASIC METABOLIC PANEL,,80048,301,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9380050,GENERAL HEALTH PANEL,,80050,301,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9380053,COMPREHENSIVE METABOLIC PANEL REF,,80053,301,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9380054,COMPREHENSIVE METABOLIC PANEL,,80053,301,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9380055,OBSTETRIC PANEL,,80055,301,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9380074,HEPATITIS ACUTE PANEL,,80074,301,$830.00 ,$830.00 ,$232.40 ,$759.45 ,$581.00 ,$694.71 ,$759.45 ,$759.45 ,$759.45 ,$305.86 ,$498.00 ,$249.00 ,$747.00 ,$622.50 ,$664.00 ,$688.90
Hoopeston Regional Hlth Center,9380150,"AMIKACIN, TROUGH, S REF",,80150,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9380158,DRUG ASSY-CARBAMAZAPN TOTL REF,,80156,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380586,"CARBAMAZEPINE, TOTAL, S REF",,80156,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9382659,DRUG ASSAY -CARBAMAZEPINE TOTL,,80156,301,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9380156,DRUG ASSY-CARBAMAZEPN FREE REF,,80157,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380585,"CARBAMAZEPINE, FREE, S REF",,80157,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386208,CYCLOSPORINE REF,,80158,301,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382087,CYCLOSPORINE ASSAY,,80158,301,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9380164,DRUG ASSY-VALPROIC ACID FRE RF,,80164,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9380165,DRUG ASSY-VALPROIC ACID TOT RF,,80164,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9380587,"VALPROIC ACID, FREE, TOTAL, S REF",,80164,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9384586,DRUG ASSAY -VALPROIC ACID,,80164,301,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9380168,ETHOSUXIMIDE REF,,80168,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9380949,"ETHOSUXIMIDE, S REF",,80168,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9380176,ASSAY LIDOCAINE,,80176,301,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9383685,DRUG ASSAY -LIDOCAINE,,80176,301,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9380124,"PHENOBARBITAL, UR REF",,80184,301,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9382656,DRUG ASSAY -PHENOBARBITAL,,80184,301,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9380468,"PHENYTOIN, TOTAL, S REF",,80185,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9384046,"PHENYTOIN, TOTAL REF",,80185,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9382655,DRUG ASSAY -PHENYTOIN,,80185,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9380467,"PHENYTOIN, FREE, S REF",,80186,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9384045,"PHENYTOIN, FREE REF",,80186,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9382646,DRUG ASSAY -PRIMIDONE,,80188,301,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9384232,QUINIDINE REF,,80194,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380085,RAPAMYCIN REF,,80195,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9380584,"SIROLIMUS, B REF",,80195,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9380197,DRUG ASSAY-TACROLIMS TROUGH RF,,80197,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9380508,"TACROLIMUS, B REF",,80197,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9380201,DRUG ASSAY -TOPIRAMATE REF,,80201,301,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380915,TOPIRAMATE REF,,80201,301,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380299,"CLOMIPRAMINE, S REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380080,DRUG ASSAY,,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380082,THERAPEUTIC DRUG ASSAY REF,,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380089,ASSAY FELBAMATE REF,,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380298,DRUG ASSAY -GABAPENTIN REF,,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380300,DRUG ASSAY -LAMOTRIGINE REF,,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380449,"NORDOXEPIN, S REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380514,"LAMOTRIGINE, S REF",,80175,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380603,"ITRACONAZOLE, S REF",,80189,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380710,"TIAGABINE, S REF",,80199,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9380717,"LEVETIRACETAM, S REF",,80177,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380918,OXCARBAZINE METAB (MHC) REF,,80183,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380939,"GABAPENTIN, S REF",,80171,301,$87.00 ,$87.00 ,$24.36 ,$79.61 ,$60.90 ,$72.82 ,$79.61 ,$79.61 ,$79.61 ,$32.06 ,$52.20 ,$26.10 ,$78.30 ,$65.25 ,$69.60 ,$72.21
Hoopeston Regional Hlth Center,9380941,"ZONISAMIDE, S REF",,80203,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380963,"FELBAMATE, S REF",,80167,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382425,DRUG ASSAY -ZONISAMIDE,,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382492,"DRUG ASSAY-CAFFEINE, SERUM REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382493,DRUG ASSY-TIAGABNE/GABITRL REF,,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382505,LEVETIRACETAM (KEPPRA) REF,,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382804,ASSY-ACETONE/OTHR KETONE AB RF,,82010,301,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9382009,B-HYDROXYBUTYRATE,,82010,301,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9382011,ACYLCARNITINE PROFILE REF,,82016,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9380708,"ACYLCARNITINES, QUANT, P REF",,82017,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382013,ACYLCARNITINE PROFILE REF,,82017,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382017,"ACYLCARNITINE, PLASMAREF REF",,82017,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380912,"ACTH, PLASMA REF",,82024,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9382024,"ACTH, PLASMA REF",,82024,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9382065,ASSAY OF SERUM ALBUMMIN REF,,82040,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9382040,"ALBUMIN, SERUM",,82040,301,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9380984,"ALBUMIN, UR OR OTHER REF",,82042,301,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9382035,ALBUMIN BODY FLUID,,82042,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9382037,ALBUMIN -SYNOVIAL FLUID,,82042,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380218,"MICROALBUMIN, URINE REF",,82043,301,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9382043,"MICROALBUMIN, URINE, QUANT",,82043,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380397,"ALDOLASE, S REF",,82085,301,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9382085,ALDOLASE REF,,82085,301,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9380409,"ALDOSTERONE, S REF",,82088,301,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9382088,"ALDOSTERONE, URINE (24H) REF",,82088,301,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9383112,"ALDOSTERONE, SERUM REF",,82088,301,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9382103,"ALPHA-1-ANTITRYPSIN, RAND, F REF",,82103,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9380480,"ALPHA-1-ANTITRYPSIN, S REF",,82103,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9380548,"ALPHA-1-ANTITRYPSIN, S REF",,82103,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9386326,"ALPHA-1-ANTITRYPSIN, TOTAL",,82103,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382104,"ALPHA-1-ANTITRYPSN,PHENOTYP RF",,82104,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380546,"A1AT PHENOTYPE, S REF",,82104,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380547,ALPHA-1-ANTITRYPSIN PHENOTYPE REF,,82104,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380144,"ALPHA-FETOPROTEIN, SERUM REF",,82105,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380519,AFP-2ND TRIM QUAD SCREEN REF,,82105,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380523,"AFP SINGLE MKR SCRN, MATNL, S REF",,82105,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382107,"ALPHA-FETOPROTEIN, SERUM REF",,82105,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382105,"ALPHA-FETOPROTEIN, SERUM",,82105,301,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9382106,"ALPHA FETOPROTEIN, AF REF",,82106,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9382112,ALPHA FETOPROTEIN AMNIOTIC REF,,82106,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9382128,AMINO ACID QUAL PLASMA REF,,82128,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9382142,AMINO ACID PROFILE REF,,82128,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9382131,"AMINO ACIDS;QUANT,EA. SPEC REF",,82131,301,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9382134,CYSTINE-QUANTITATIVE-URINE REF,,82131,301,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9382135,"AMINOLEVULINIC ACID, URINE REF",,82135,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9382137,"AMINOLEVULINIC ACID, URINE REF",,82135,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9382136,"AMINO ACIDS,2-5 QNT. REF",,82136,301,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9382139,AMINO ACIDS 6/>QUANT EA/SPC RF,,82139,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380445,"AMINO ACIDS, QN, P REF",,82139,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380492,"AMINO ACIDS, QN, RANDOM, U REF",,82139,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382155,AMINO ACIDS 6/>QUANT EA/SPC RF,,82139,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380331,AMMONIUM URINE,,82140,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9382140,AMMONIA,,82140,301,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9380945,"PANCREATIC AMYLASE, SERUM REF",,82150,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9382159,AMYLASE ISOENZYMES REF,,82150,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9382150,AMYLASE,,82150,301,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9380944,"ANDROSTENEDIONE, S REF",,82157,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9382157,ANDROSTENEDIONE REF,,82157,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9380980,"ANGIOTENSIN CONV ENZ (ACE), CSF REF",,82164,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9382164,"ANGIOTENSIN CONVERT. ENZYME, S REF",,82164,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9383498,ANGIOTENSIN I-CONV ENZYME REF,,82164,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9382172,"APOLIPOPROTEIN A1 AND B, P REF",,82172,301,$84.00 ,$84.00 ,$23.52 ,$76.86 ,$58.80 ,$70.31 ,$76.86 ,$76.86 ,$76.86 ,$30.95 ,$50.40 ,$25.20 ,$75.60 ,$63.00 ,$67.20 ,$69.72
Hoopeston Regional Hlth Center,9380416,"ARSENIC, 24 HR, U REF",,82175,301,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9380920,"ARSENIC, BLOOD REF",,82175,301,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9382175,"ARSENIC, BLOOD REF",,82175,301,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9382176,"ARSENIC, URINE (24HR) REF",,82175,301,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9382180,VITAMIN C LEVEL IN BLOOD REF,,82180,301,$40.00 ,$40.00 ,$11.20 ,$36.60 ,$28.00 ,$33.48 ,$36.60 ,$36.60 ,$36.60 ,$14.74 ,$24.00 ,$12.00 ,$36.00 ,$30.00 ,$32.00 ,$33.20
Hoopeston Regional Hlth Center,9380441,"BETA-2-MICROGLOBULIN, S REF",,82232,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9382232,BETA-2 MICROGLOBULIN REF,,82232,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9380226,"BILIRUBIN, TOTAL REF",,82247,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9382247,"BILIRUBIN, TOTAL",,82247,301,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9382248,"BILIRUBIN, DIRECT",,82248,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9384311,NBS-BIOTINIDASE DEFIC SCRN REF,,82261,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9384312,ASSAY -BIOTINIDASE REF,,82261,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382272,OCCULT BLOOD -SINGLE SPECIMEN,,82272,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9380620,FECAL OCCULT BLOOD,,82274,301,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9380420,"CADMIUM, URINE (24HR) REF",,82300,301,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9380919,"CADMIUM, BLOOD REF",,82300,301,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9382300,"CADMIUM, BLOOD REF",,82300,301,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9382301,"CADMIUM, URINE (24HR) REF",,82300,301,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9382058,VITAMIN D3 (25-HYDROXY) REF,,82306,301,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9382059,VITA-D 25 HYDROXY SRM,,82306,301,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9382306,25 OH VITAMIN D TOTAL,,82306,301,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,9380932,"CALCITONIN, SERUM REF",,82308,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9382315,CALCITONIN REF,,82308,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9382309,CALCIUM (PTH-INTACT) REF,,82310,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382310,"CALCIUM, TOTAL",,82310,301,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9380324,CALCIUM URINE,,82340,301,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9380596,"CALCIUM, U REF",,82340,301,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9382340,"CALCIUM, URINE",,82340,301,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9380413,KIDNEY STONE ANALYSIS REF,,82365,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380414,"LEAD, URINE (24HR) REF",,82365,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9382365,KIDNEY STONE ANALYSIS REF,,82365,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9382374,CARBON DIOXIDE (BICARBONATE),,82374,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9382942,CEA REF,,82378,301,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9380429,"CARNITINE, FRACTIONATED REF",,82379,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382345,"CARNITINE,TOTAL&FREE,QUANT REF",,82379,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382379,"CARNITINE, FRACTIONATED REF",,82379,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380957,CAROTENE REF,,82380,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9382380,CAROTENE REF,,82380,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9383120,"CATECHOLAMINE FRACT, FREE, U REF",,82384,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9382384,"CATECHOLAMINES FRC, UR REF",,82384,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9382400,"CATECHOLAMINES,FRACTIONATD REF",,82384,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9380349,CHEMILUMINESCENT ASSAY (SGI-PROMETH),,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9382372,CHEMILUMINESCENT ASSAY REF,,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9383513,ASSAY -ENDOCRINE HORMONE REF,,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9384483,"PTH RELATED PEPTIDE, P REF",,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9380598,"CHLORIDE, U REF",,82436,301,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9382436,"CHLORIDE, URINE",,82436,301,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9380405,"PSEUDOCHOLINESTERASE, TOTAL, S REF",,82480,301,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9382480,"CHOLINESTERASE, PLASMA REF",,82480,301,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9380406,"ACETYLCHOLINESTERASE, RBC REF",,82482,301,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9382482,"CHOLINESTERASE, RBC REF",,82482,301,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9380931,"CHROMIUM, SERUM REF",,82495,301,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9382495,"CHROMIUM, BLOODREF REF",,82495,301,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9380013,ASSAY CITRATE REF,,82507,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9380327,CITRATE URINE,,82507,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9380450,"CITRATE EXCRETION, U REF",,82507,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9380145,COLLAGEN CROSS LINK REF,,82523,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380720,"BETA-CROSSLAPS (B-CTX), S REF",,82523,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382523,N-TELOPEPTIDE (NTX) UR REF,,82523,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380411,"COPPER, 24 HR, U REF",,82525,301,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9380934,"COPPER, SERUM REF",,82525,301,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9382525,"COPPER, PLASMA REF",,82525,301,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9386130,COPPER -URINE (24HR) REF,,82525,301,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9380408,"CORTISOL, FREE, URINE REF",,82530,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380745,"CORTISOL, SALIVA REF",,82533,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9382530,"CORTISOL, FREE, URINE REF",,82530,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382533,"CORTISOL, TOTAL REF",,82533,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9383180,"CORTISOL, TOTAL",,82533,301,$325.00 ,$325.00 ,$91.00 ,$297.38 ,$227.50 ,$272.03 ,$297.38 ,$297.38 ,$297.38 ,$119.76 ,$195.00 ,$97.50 ,$292.50 ,$243.75 ,$260.00 ,$269.75
Hoopeston Regional Hlth Center,9380781,CREATINE REF,,82540,301,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9382540,CREATINE REF,,82540,301,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9382070,CANNABINOIDS CONF UR REF,,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382546,CHROMTGRPHY/SPECTRMTRY QUA REF,,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382606,THC -QUANT- CONFIRMATION REF,,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9380510,TOTAL CK ACTIVITY REF,,82550,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9382556,CK TOTAL REF,,82550,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9382550,CREATINE KINASE CK/CPK/TOTAL,,82550,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382555,CK TOTAL,,82550,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380509,"CK ISOENZYME ELECTROPH, S REF",,82552,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9382553,CK ISOENZYMES REF,,82552,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9380333,CREATININE URINE,,82570,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9380701,"CITRATE EXCRETION, U REF",,82570,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9380705,"CREATININE, U REF",,82570,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9380782,CREATININE REF,,82570,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382564,"CREATININE, RANDOM URINE REF",,82570,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382571,"CREATININE, URINE, RANDOM REF",,82570,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382573,CREATININE UR REF,,82570,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382570,"CREATININE, OTHER SOURCE",,82570,301,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9380736,"CRYOFIBRINOGEN, P REF",,82585,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9382585,"CRYOFIBRINOGEN, PLASMA REF",,82585,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9380735,"CRYOGLOBULIN, S REF",,82595,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9382595,"CRYOGLOBULIN, SERUM REF",,82595,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9382600,CYANIDE REF,,82600,301,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9382605,CYANOCOBALAMIN VIT B12 REF,,82607,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9382607,VITAMIN B12,,82607,301,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9380132,CYSTATIN C TEST REF,,82610,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380966,"DHEA, SERUM REF",,82626,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9382626,DHEA UNCONJUGATED REF,,82626,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9380401,DEHYDROEPIANDROSTERONE SULFATE REF,,82627,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382627,DHEA SULPHATE REF,,82627,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382633,"DESOXYCORTISTERONE, 11- REF",,82633,301,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9380244,DEOXYCORTICOSTERONE REF,,82633,301,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9383620,11-DEOXYCORTISOL REF,,82634,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9380431,"1,25-DIHYDROXYVITAMIN D, S REF",,82652,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9382652,"VITAMIN D 1,25-DIHYDROXY REF",,82652,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9383510,"PANCREATIC ELASTASE, F REF",,82656,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380339,ENZYME ACTIVITY NES NONRAD (TPMT ENZ-PROMETH),,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9380849,DISACCHARIDASE ANALYSIS REF,,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382674,ENZYME ACTIVITY NES NONRAD REF,,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382678,ENZYME ACTIVITY NES NONRAD REF,,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382691,ENZYME CELL ACTVTY EA SPEC REF,,82658,301,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9380388,IEF CONFIRMS REF,,82664,301,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9382676,ELECTROPHORETIC TEST -REF,,82664,301,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9380495,"ERYTHROPOIETIN (EPO), S REF",,82668,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382668,ERYTHROPOIETIN REF,,82668,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9380747,"ESTRADIOL, S REF",,82670,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9382670,ESTRADIOL,,82670,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9383246,ASSAY -ESTRADIOL,,82670,301,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9382672,ESTROGEN TOTAL REF,,82672,301,$87.00 ,$87.00 ,$24.36 ,$79.61 ,$60.90 ,$72.82 ,$79.61 ,$79.61 ,$79.61 ,$32.06 ,$52.20 ,$26.10 ,$78.30 ,$65.25 ,$69.60 ,$72.21
Hoopeston Regional Hlth Center,9380520,UE3-2ND TRIM QUAD SCREEN REF,,82677,301,$97.00 ,$97.00 ,$27.16 ,$88.76 ,$67.90 ,$81.19 ,$88.76 ,$88.76 ,$88.76 ,$35.74 ,$58.20 ,$29.10 ,$87.30 ,$72.75 ,$77.60 ,$80.51
Hoopeston Regional Hlth Center,9384472,ESTRIOL ASSAY REF,,82677,301,$97.00 ,$97.00 ,$27.16 ,$88.76 ,$67.90 ,$81.19 ,$88.76 ,$88.76 ,$88.76 ,$35.74 ,$58.20 ,$29.10 ,$87.30 ,$72.75 ,$77.60 ,$80.51
Hoopeston Regional Hlth Center,9382677,"ESTRIOL, UNCONJUGATED",,82677,301,$670.00 ,$670.00 ,$187.60 ,$613.05 ,$469.00 ,$560.79 ,$613.05 ,$613.05 ,$613.05 ,$246.90 ,$402.00 ,$201.00 ,$603.00 ,$502.50 ,$536.00 ,$556.10
Hoopeston Regional Hlth Center,9380526,"ESTRONE, S REF",,82679,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9380746,MAG AB WESTERN BLOT REF,,84181,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9382679,ESTRONE REF,,82679,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9382693,ETHYLENE GLYCOL REF,,82693,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9382710,FECAL FAT/LIPIDS QUANTITTVE RF,,82710,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382725,FATTY ACIDS NON ESTERIFIED REF,,82725,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382726,"FATTY ACID PROFILE, PEROXISOMAL REF",,82726,301,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9382727,FATTY ACIDS-VERY LNG CHAIN REF,,82726,301,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9380935,CENTROMERE ABS REF,,82728,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9380245,FERRITIN REF,,82728,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9383014,FERRITIN,,82728,301,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9382735,"FLUORIDE, P REF",,82735,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9382746,FOLIC ACID SERUM REF,,82746,301,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9382743,"FOLIC ACID (FOLATE), SERUM",,82746,301,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9380491,"FOLATE, RBC REF",,82747,301,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9382747,"FOLIC ACID (FOLATE), RBC REF",,82747,301,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9382760,GALACTOSEMIA SCREEN REF,,82760,301,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9382775,ASSAY GALACTOSE TRANSFERASE-RE,,82775,301,$84.00 ,$84.00 ,$23.52 ,$76.86 ,$58.80 ,$70.31 ,$76.86 ,$76.86 ,$76.86 ,$30.95 ,$50.40 ,$25.20 ,$75.60 ,$63.00 ,$67.20 ,$69.72
Hoopeston Regional Hlth Center,9380368,TOTAL IGA (CELIAC-PROMETH),,82784,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9380371,"IMMUNOGLOBULIN A (IGA), S REF",,82784,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9380443,TOTAL IGG REF,,82784,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9380616,"IMMUNOGLOB; IGA, D, G, OR M, EACH REF",,82784,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9382780,GAMMAGLOBULIN IGG TOTAL REF,,82784,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9382784,GAMMAGLOBULIN IGA/IGD/IGG/IGM,,82784,301,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9380383,"IMMUNOGLOBULIN E (IGE), S REF",,82785,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9382783,GAMMAGLOBULIN REF,,82785,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9382787,GAMMAGLOBULIN IGE REF,,82785,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9380444,"IGG SUBCLASSES, S REF",,82787,301,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9382790,IMMUNOGLOBULIN SUBCLASSES REF,,82787,301,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9382946,GASTRIN REF,,82941,301,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9380926,GASTRIN REF,,82941,301,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9383016,GASTRIN REF,,82941,301,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9382943,"GLUCAGON, P REF",,82943,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9380451,"GLUCAGON, P REF",,82943,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9382945,GLUCOSE BODY FLUID REF,,82945,301,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9389072,GLUCOSE BODY FLUID (CSF),,82945,301,$90.00 ,$90.00 ,$25.20 ,$82.35 ,$63.00 ,$75.33 ,$82.35 ,$82.35 ,$82.35 ,$33.17 ,$54.00 ,$27.00 ,$81.00 ,$67.50 ,$72.00 ,$74.70
Hoopeston Regional Hlth Center,9382949,GLUCOSE MISC REF,,82947,301,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9382947,"GLUCOSE, QUANTITATIVE",,82947,301,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382951,GLUCOSE 2 HR PP,,82947,301,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9384330,GLUCOSE BLOOD,,82947,301,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9380958,"G-6-PD QNT, ERYTHROCYTES REF",,82955,301,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9382955,"G6PD, QUANTITATIVE REF",,82955,301,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9382961,G6PD SCREEN REF,,82960,301,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9382960,G6PD SCREEN,,82960,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380971,"FRUCTOSAMINE, S REF",,82985,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382985,GLYCATD PROTEIN -FRUCTOSAMN RF,,82985,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9383001,FSH REF,,83001,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9383311,FOLLICLE STIMULATING HORMONE,,83001,301,$410.00 ,$410.00 ,$114.80 ,$375.15 ,$287.00 ,$343.17 ,$375.15 ,$375.15 ,$375.15 ,$151.09 ,$246.00 ,$123.00 ,$369.00 ,$307.50 ,$328.00 ,$340.30
Hoopeston Regional Hlth Center,9383012,LUTEINIZING HORMONE TEST REF,,83002,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9383304,LUTEINIZING HORMONE (LH),,83002,301,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9380423,"GROWTH HORMONE, S REF",,83003,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9383003,HUMAN GROWTH HORMONE REF,,83003,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380306,"COBALT, BLOOD REF",,83018,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9380864,"BERYLLIUM, BLOOD REF",,83018,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9383018,COBALT REF,,83018,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9383040,"HEAVY METAL,QUANTITATVE,EA REF",,83018,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9383020,"HGB FRACT & QUANT, ELP REF",,83020,301,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9380385,"HEMOGLOBIN ELECTROPH, B REF",,83020,301,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9380386,HEMOGLOBIN A2 AND F REF,,83021,301,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382487,NBS-SICKLE CELL SCRN REF,,83021,301,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9383019,HGB CHROMATOGRAPHY REF,,83021,301,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9383030,FETAL HEMOGLOBIN REF,,83030,301,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9383610,"HEMOGLOBIN, GLYCATED (A1C) REF",,83036,301,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9383036,GLYCOSYLATED HEMOGLOBIN -REF,,83036,301,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9383025,"HEMOGLOBIN, GLYCATED (A1C)",,83036,301,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9383051,"HEMOGLOBIN, PLASMA",,83051,301,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9383068,"HEMOGLOBIN, UNSTABLE, B REF",,83068,301,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,9383069,"HEMOGLOBIN, URINE REF",,83069,301,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9383070,HEMOSIDERIN URINE QUALITATIVE,,83070,301,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9384313,HEXO A + TOTAL SERUM REF,,83080,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9384315,HEXO A/ HEXO TOTAL REF,,83080,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9383088,ASSAY HISTAMINE,,83088,301,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9383090,HOMOCYSTINE LEVEL REF,,83090,301,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382944,HOMOCYSTEINE ASSAY,,83090,301,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9383093,HOMOVANILLIC ACID(HVA)REF REF,,83150,301,$90.00 ,$90.00 ,$25.20 ,$82.35 ,$63.00 ,$75.33 ,$82.35 ,$82.35 ,$82.35 ,$33.17 ,$54.00 ,$27.00 ,$81.00 ,$67.50 ,$72.00 ,$74.70
Hoopeston Regional Hlth Center,9383150,"HOMOVANILLIC ACID(HVA), 24HR, U REF",,83150,301,$90.00 ,$90.00 ,$25.20 ,$82.35 ,$63.00 ,$75.33 ,$82.35 ,$82.35 ,$82.35 ,$33.17 ,$54.00 ,$27.00 ,$81.00 ,$67.50 ,$72.00 ,$74.70
Hoopeston Regional Hlth Center,9380442,"5-HYDROXYINDOLEACETIC ACID, U REF",,83497,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9383493,HYDRXYINDOLCTEIC ACID 5HIAA RF,,83497,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380440,"17-HYDROXYPROGESTERONE, S REF",,83498,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9382163,"OH-PROGESTERONE, 17-ALPHA REF",,83498,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9383496,"OH-PROGESTERONE, 17-ALPHA REF",,83498,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9383499,NBS-CONGEN ADRENAL HYPERPL SCRN REF,,83498,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9382236,"TISS TRANSGLUTAMIN AB, IGG, S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383086,"IA ANALYTE, QUAL/SEMIQUANT REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383494,"TISS TRANSGLUTAMIN AB, IGA, S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380134,NBS-CYCSTIC FIBROSIS SCRN REF,,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380373,"GLIADIN(DEAMIDATED) AB, IGA, S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380374,"GLIADIN(DEAMIDATED) AB, IGG, S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380453,"MPO AB AND PR3 AB, S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380501,"MYELOPEROXIDASE AB, S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380713,"PROTEINASE 3 AB (PR3), S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380808,"GLIADIN (DEAMIDATED) AB EVAL, S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380850,MUSK ANTIBODY REF,,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380853,MYOSITIS ANTIBODY PANEL REF,,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380948,"PARIETAL CELL AB, IGG, S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383531,GLIADIN ANTIBODIES,,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383546,CYSTIC FIBROSIS REF,,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380311,TISSUE TRANSGLUT. IGA,,83516,301,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9380489,PANCREASTATIN REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380560,P/Q-TYPE CALCIUM CHANNEL AB REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380561,N-TYPE CALCIUM CHANNEL AB REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380562,ACH RECEP (MUSCLE) BINDING AB REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380563,"ACHR GANGLIONIC NEURONAL AB, S REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380564,"NEURONAL (V-G) K+ CHNL AB, S REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380568,ACH RECEPTOR (MUSCLE) MOD AB REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380734,"MYASTHENIA GRAVIS EVAL, PED. REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380914,ACETYCHOLINE RECEP BINDING AB REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380928,THYROTROPIN RECEP AB REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380954,"PANCREATIC POLYPEPTIDE, PL REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380959,"MOTILIN, S REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380962,SUBSTANCE P REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9382014,ACETYCHOLINE RECEPTOR ASSAY RF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9382096,PANCREATIC POLYPEPTIDE REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9382420,GLUTAMC ACID DECRBXYLSE AB REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9383485,"IMMUNOASSAY,ANALYTE,QUANT. REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9383555,IMMUNO ASSAY MOTILIN,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9384236,ACETYLCHLNE RCPTR BLCKNG AB RF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9384238,ACETYLCHLN RCPTR MODULAT AB RF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380090,"RIBOSOME P AB, IGG, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380092,NMO EVAL W/REFLEX S [60796],,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380346,SERUM INFLIXIMAB (PROMETHEUS),,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380347,IMMUNOASSAY ANALYTE QT (SGI-PROMETH),,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380348,IMMUNOASSAY ANALYTE QT (SGI-PROMETH),,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380356,IMMUNOASSAY ANALYTE QT (CROHN'S RFLX-PROMETH),,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380360,IMMUNOASSAY ANALYTE QT (CROHN'S-PROMETH),,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380365,"DEAMINATED GLIADIN PEPTIDE AB, IGA/IGG (CELIAC-PROME)",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380366,"ANTI-HUMAN TTG, ELISA (CELIAC-PROMETH)",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380381,"CENTROMERE AB, IGG, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380425,"STRIATIONAL MUSCLE AB, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380426,"CAFFEINE, S REF",,80155,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9380436,ALPHASUBUNIT PITUIT TUMOR MRKR REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380507,"MAG AB, DUAL ELISA, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380559,"STRIATED MUSCLE AB, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380711,"14-3-3 PROTEIN, CSF REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380728,"IGFBP-3, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380788,"INHIBIN B, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380852,PIVKA-II REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380956,"TRYPTASE, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380970,"ANTIMULLERIAN HORMONE (AMH), S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383514,"IMMUNOASSAY,ANALYTE,QUANT. REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383518,SUBSTANCE-P,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383524,GLOMERULAR BASE MEM AB REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383576,IMMUNOASSAY ANALYTE QUANT REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380417,"INSULIN, S REF",,83525,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383390,INSULIN REF,,83525,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383600,LACTIC ACID (LACTATE) REF,,83605,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383605,LACTIC ACID,,83605,301,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9380421,"LACTATE DEHYDROGENASE (LD), S REF",,83615,301,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9383616,LACTATE DEHYDROGENASE TOTL REF,,83615,301,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9383615,LACTATE DEHYDROGENASE (LD/LDH),,83615,301,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9380422,"LD ISOENZYMES, S REF",,83625,301,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9383625,LD ISOENZYMES REF,,83625,301,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9383630,"LACTOFERRIN, QL, STOOL REF",,83630,301,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9380335,"LACTOFERRIN, FECAL, QUAL.",,83630,301,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9380137,LACTOFERRN FECL QUANTITATV REF,,83631,301,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9380336,"LACTOGEN, HUMAN PLACENTAL REF",,83632,301,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9382039,LEAD REF,,83655,301,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380469,"LEAD, B REF",,83655,301,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9383655,"LEAD, BLOOD REF",,83655,301,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9383660,"LEAD, URINE (24HR) REF",,83655,301,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9384680,"L/S RATIO, AMNIO REF",,83661,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9383661,L/S RATIO,,83661,301,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9383663,FLURO POL FETAL LUNG REF,,83663,301,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9380968,"LIPOPROTEIN (A), S REF",,83695,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9383695,LIPOPROTEIN ASSAY REF,,83695,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9383701,LIPOPROTEIN BLD HR FRACTION-RE,,83701,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9380130,NMR LIPOPROTEIN QNT PART REF,,83704,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9383718,HDL CHOLESTEROL,,83718,301,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9383631,"LDL CHOLESTEROL, DIRECT",,83721,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380330,MAGNESIUM URINE,,83735,301,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9380597,"MAGNESIUM, U REF",,83735,301,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9383737,"MAGNESIUM, FECES REF",,83735,301,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9383735,MAGNESIUM,,83735,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9383736,"MAGNESIUM, URINE",,83735,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9380088,DRUG ASSAY -OXCARBAZEPINE REF,,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9380387,"HB VARIANT BY MASS SPEC, B REF",,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9380415,"THALLIUM, 24 HR, U REF",,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9380494,"PYRIDOXIC ACID (PA), P REF",,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9380783,GUANIDINOACETATE REF,,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9380859,"BILE ACIDS, FRACTIONATED REF",,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9380933,"COBALT, SERUM REF",,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382418,MASS SPECTROMTRY-EA SPECIMN RF,,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9383789,MASS/TANDM MASS SPECTROMTRY RF,,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9380412,"MERCURY, URINE (24HR) REF",,83825,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9380712,"MERCURY OCCUP MONITOR, U REF",,83825,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9380917,MERCURY BLOOD REF,,83825,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9382235,"MERCURY, URINE(24HR)",,83825,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9383830,"MERCURY, URINE (24HR) REF",,83825,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9383831,MERCURY BLOOD REF,,83825,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9380716,"METANEPHRINES, FRACT, 24H, U REF",,83835,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9383680,"METANEPHRINES, PLASMA REF",,83835,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9383835,"METANEPHRINES, URINE(24HR) REF",,83835,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9383145,METANEPHRINE URINE TOTAL,,83835,301,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9383872,"MUCIN, SYNOVIAL FLUID(ROPES TE",,83872,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9380927,"MYOGLOBIN, URINE REF",,83874,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380950,"MYOGLOBIN, SERUM REF",,83874,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9383874,"MYOGLOBIN, SERUM REF",,83874,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380972,NATRIURETIC PEPTIDE REF,,83880,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9383534,B-NATRIURETIC PEPTIDE,,83880,301,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9384474,"NEPHELOMETRY, EACH ANALYTE REF",,83883,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9384645,"NEPHELOMETRY, EACH ANALYTE REF",,83883,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9380037,IMMUNOGLOB FREE LIGHT CHAINS,,83883,301,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9383883,"ALBUMIN,CSF",,83883,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9383915,NUCLEOTIDASE-5 REF,,83915,301,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9383918,"ORGANIC ACIDS, QUANT EACH REF",,83918,301,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9383750,ORGANIC ACIDS-EACH SPECIMN REF,,83919,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9383920,"ORGANIC ACIDS, QUAL, URINE REF",,83919,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9382791,"METHYLMALONIC ACID, QN, U REF",,83921,301,$85.00 ,$85.00 ,$23.80 ,$77.78 ,$59.50 ,$71.15 ,$77.78 ,$77.78 ,$77.78 ,$31.32 ,$51.00 ,$25.50 ,$76.50 ,$63.75 ,$68.00 ,$70.55
Hoopeston Regional Hlth Center,9383730,"METHYLMALONIC ACID, QN, S REF",,83921,301,$85.00 ,$85.00 ,$23.80 ,$77.78 ,$59.50 ,$71.15 ,$77.78 ,$77.78 ,$77.78 ,$31.32 ,$51.00 ,$25.50 ,$76.50 ,$63.75 ,$68.00 ,$70.55
Hoopeston Regional Hlth Center,9383921,ORGANIC ACID SINGLE QUANT REF,,83921,301,$85.00 ,$85.00 ,$23.80 ,$77.78 ,$59.50 ,$71.15 ,$77.78 ,$77.78 ,$77.78 ,$31.32 ,$51.00 ,$25.50 ,$76.50 ,$63.75 ,$68.00 ,$70.55
Hoopeston Regional Hlth Center,9383919,METHYLMALONIC ACID REF,,83921,301,$85.00 ,$85.00 ,$23.80 ,$77.78 ,$59.50 ,$71.15 ,$77.78 ,$77.78 ,$77.78 ,$31.32 ,$51.00 ,$25.50 ,$76.50 ,$63.75 ,$68.00 ,$70.55
Hoopeston Regional Hlth Center,9380706,"OSMOLALITY,U REF",,83935,301,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9383935,"OSMOLALITY, URINE",,83935,301,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9383937,"OSTEOCALCIN, SERUM REF",,83937,301,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9380325,OXALATE URINE,,83945,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380419,OXALATE URINE (24HR) REF,,83945,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380702,"OXALATE, U REF",,83945,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9383945,OXALATE URINE (24HR) REF,,83945,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9383951,DES-GAMMA-CARBOXY-PROTHROMBIN,,83951,301,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9380323,PH URINE,,83986,301,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9380703,"PH, U REF",,83986,301,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9383986,"PH, BODY FLUID, EXCEPT BLOOD",,83986,301,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9383626,"PHENCYCLIDINE CONF, URREF REF",,83992,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9383993,CALPROTECTIN FECAL REF,,83993,301,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9384067,PROSTATIC ACID PHOSPHATASE REF,,84066,301,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9380819,ALKALINE PHOSPHATASE S REF,,84075,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9384039,"ALKALINE PHOSPHATASE,TOTAL REF",,84075,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9384075,ALKALINE PHOSPHATASE,,84075,301,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9380714,"BONE ALKALINE PHOSPHATASE, S REF",,84080,301,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9380820,ALKALINE PHOS ISOENZYMES S REF,,84080,301,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9384080,ALK PHOS ISOENZYMES REF,,84080,301,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9382245,AMNIOTIC FLUID ENZYME TEST REF,,84081,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9384081,PHOPHATIDYLGLYCEROL (IA MTHD),,84081,301,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9384100,PHOSPHORUS INORGAN (PHOSPHATE),,84100,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380329,PHOSPHORUS URINE,,84105,301,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9380599,"PHOSPHORUS, U REF",,84105,301,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9384105,"PHOSPHORUS, URINE",,84105,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9384317,"PHOSPHORUS, RANDOM URINE",,84105,301,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9384110,"PORPHOBILINOGEN, U REF",,84110,301,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,9380410,PORPHOBILINOGEN URINE QNT REF,,84110,301,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,9384139,PORPHYRIN FRAC RANDOM UR REF,,84120,301,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9380332,POTASSIUM URINE,,84133,301,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9380595,"POTASSIUM, U REF",,84133,301,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9384133,"POTASSIUM, URINE",,84133,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380142,"PREGNENOLONE, S REF",,84140,301,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9384143,17 HYDROXYPREGNENOLONE REF,,84143,301,$91.00 ,$91.00 ,$25.48 ,$83.27 ,$63.70 ,$76.17 ,$83.27 ,$83.27 ,$83.27 ,$33.53 ,$54.60 ,$27.30 ,$81.90 ,$68.25 ,$72.80 ,$75.53
Hoopeston Regional Hlth Center,9384144,PROGESTERONE REF,,84144,301,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9383350,PROGESTRONE,,84144,301,$375.00 ,$375.00 ,$105.00 ,$343.13 ,$262.50 ,$313.88 ,$343.13 ,$343.13 ,$343.13 ,$138.19 ,$225.00 ,$112.50 ,$337.50 ,$281.25 ,$300.00 ,$311.25
Hoopeston Regional Hlth Center,9380148,PROCALCITONIN,,84145,301,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9384147,ASSAY PROLACTIN,,84146,301,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9384146,PROLACTIN,,84146,301,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9384150,PROSTAGLANDIN,,84150,301,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9380591,TOTAL PSA REF,,84153,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9384152,PSA TOTAL REF,,84153,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380592,FREE PSA REF,,84154,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9384154,PSA FREE,,84154,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9384635,PROTEIN ASSAY REF,,84155,301,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9384155,"PROTEIN, TOTAL, SERUM",,84155,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9384158,PROTEIN TOTAL UR REF,,84156,301,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9384156,"PROTEIN, TOTAL, URINE",,84156,301,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9380619,"PROTEIN, TOTAL, OTHER SOURCE REF",,84157,301,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9384157,"PROTEIN, TOTAL, OTHER SOURCE",,84157,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9384167,PROTEIN ELP FRACT&QT W/CONC REF,,84166,301,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9382170,"PROT ELE PHO OTHR(CSF,URINE)QN",,84166,301,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9386425,PROTEIN ELP FRACT&QUANT OTH FL,,84166,301,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9384181,"PROTEIN, WESTERN BLOT REF",,84181,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9380566,"CRMP-5-IGG WESTERN BLOT, S REF",,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9380567,"PARANEOPLASTIC AUTOAB WBLOT,S REF",,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9380569,"AMPHIPHYSIN WESTERN BLOT, S REF",,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9380601,BOTULINUM TOXIN TYPE A AB REF,,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9384182,PROTEIN-WESTERN BLOT TEST REF,,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9380916,"ZINC PROTOPORPHYRIN, BLOOD REF",,84202,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9384202,PROTOPORPHYRIN -ZINC- REF,,84202,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9384206,PROINSULIN REF,,84206,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9380493,"PYRIDOXAL 5-PHOSPHATE (PLP), P REF",,84207,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9384207,VITAMIN B6 REF,,84207,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9380377,"RENIN ACTIVITY, P REF",,84244,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9383360,"RENIN ACTIVITY, PLASMA REF",,84244,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9384252,VITAMIN B2-RIBOFLAVIN REF,,84252,301,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9384255,ASSAY SELENIUM REF,,84255,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9380940,"SEROTONIN, BLOOD REF",,84260,301,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9384260,"SEROTONIN, BLOOD REF",,84260,301,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9380951,"SEX HORMONE BINDING GLOBULIN, S REF",,84270,301,$87.00 ,$87.00 ,$24.36 ,$79.61 ,$60.90 ,$72.82 ,$79.61 ,$79.61 ,$79.61 ,$32.06 ,$52.20 ,$26.10 ,$78.30 ,$65.25 ,$69.60 ,$72.21
Hoopeston Regional Hlth Center,9384270,ASSAY SEX HORMONE GLOBUL REF,,84270,301,$87.00 ,$87.00 ,$24.36 ,$79.61 ,$60.90 ,$72.82 ,$79.61 ,$79.61 ,$79.61 ,$32.06 ,$52.20 ,$26.10 ,$78.30 ,$65.25 ,$69.60 ,$72.21
Hoopeston Regional Hlth Center,9380328,SODIUM URINE,,84300,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9380594,"SODIUM, U REF",,84300,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9384300,"SODIUM, URINE",,84300,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9384302,"SODIUM, RANDOM, F REF",,84302,301,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9384296,"SODIUM, BODY FLUID",,84302,301,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9384307,SOMATOSTATIN,,84307,301,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9384309,SPECTROPHOTOMETRY -ANALYTE REF,,84311,301,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9380517,"PORPHYRINS, TOTAL, P REF",,84311,301,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9384448,SPECTROPHOTOMETRY,,84311,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9384376,SUGARS; SNGL QUAL EA REF,,84376,301,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9384377,SUGARS -EACH SPECIMEN REF,,84377,301,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9384378,SUGAR SINGL QUANT EA SPEC REF,,84378,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380499,"GALACTOSE-1-PHOSPHATE, RBC REF",,84378,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9384379,"SUGARS, MULT QUANT EACH REF",,84379,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380700,"SULFATE, U REF",,84392,301,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9384392,SULPHATE URINE,,84392,301,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9380738,"TESTOSTERONE, FREE, BIOAVAIL, S REF",,84402,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9384402,"TESTOSTERONE, FREE, S REF",,84402,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9380404,"TESTOSTERONE, TOTAL, S REF",,84403,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9380737,"TESTOSTERONE, TOTAL, S REF",,84403,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9384403,ASSAY TOTAL TESTOSTERONE REF,,84403,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9383405,TESTOSTERONE,,84403,301,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9380515,"THIAMIN (VITAMIN B1), WB REF",,84425,301,$85.00 ,$85.00 ,$23.80 ,$77.78 ,$59.50 ,$71.15 ,$77.78 ,$77.78 ,$77.78 ,$31.32 ,$51.00 ,$25.50 ,$76.50 ,$63.75 ,$68.00 ,$70.55
Hoopeston Regional Hlth Center,9384425,VITAMIN B-1 (THIAMINE) REF,,84425,301,$85.00 ,$85.00 ,$23.80 ,$77.78 ,$59.50 ,$71.15 ,$77.78 ,$77.78 ,$77.78 ,$31.32 ,$51.00 ,$25.50 ,$76.50 ,$63.75 ,$68.00 ,$70.55
Hoopeston Regional Hlth Center,9380981,"THYROGLOBULIN, TUMOR MARKER, S REF",,84432,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9384433,"THYROGLOBULIN, QUANT. REF",,84432,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9380424,"T4 (THYROXINE), TOTAL ONLY, S REF",,84436,301,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9384436,"THYROXINE, TOTAL (T4) REF",,84436,301,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9383455,T-4,,84436,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9384439,T4 (THYROXIN T4) FREE,,84439,301,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9384438,"THYROXINE, FREE (T4)",,84439,301,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9384442,THYROXINE BINDING GLOBULIN REF,,84442,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9384443,HHC NBS-HYPYOTHYROIDISM SCRN REF,,84443,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9383480,TSH,,84443,301,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9380930,"TSI, SERUM REF",,84445,301,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9384445,TSI (THYROID STIM. IMMUREF REF,,84445,301,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380923,VITAMIN E REF,,84446,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9382060,VITAMIN E (TOCOPHEROL) REF,,84446,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9384460,"TRANSFERASE, ALANINE AMINO",,84460,301,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9384476,TRIGLYCERIDES,,84478,301,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9384478,TRIGLYCERIDES,,84478,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9380921,T-UPTAKE REF,,84479,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9384479,THYROID HORMONE(T3) UPTAKE REF,,84479,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9383465,T UPTAKE,,84479,301,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9380452,"T3 (TRIIODOTHYRONINE), FREE, S REF",,84481,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9384481,"TRIIODOTHYRONINE T3, FREE REF",,84481,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9384482,TRIIODOTHYRONINE T3 REVERS REF,,84482,301,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,9384540,"UREA NITROGEN, URINE",,84540,301,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9380326,URIC ACID URINE,,84560,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9380704,"URIC ACID, U REF",,84560,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9384560,"URIC ACID, OTHER SOURCE",,84560,301,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9384561,"URIC ACID, RANDOM URINE",,84560,301,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9383140,"VMA, URINE (ADULT)",,84585,301,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9384585,VANILLYMANDELIC ACID REF,,84585,301,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9384589,VANILLYLMANDELIC ACID(VMA) REF,,84585,301,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9380952,"VASOACT INTEST POLYPEPTIDE, P REF",,84586,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9384584,VASOACTVE INTESTNAL PEPTDE REF,,84586,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9384588,"ARGININE VASOPRESSIN, P REF",,84588,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9380922,VITAMIN A REF,,84590,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9384595,VITAMIN A (RETINOL) REF,,84590,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380969,NIACIN VITAMIN B3 REF,,84591,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9384591,ASSAY OF VITAMIN REF,,84591,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9384575,"VITAMIN K, SERUM REF",,84597,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9380865,"BENZENE AS PHENOL, OCC EXP, U REF",,84600,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9384600,VOLATILES REF,,84600,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9380929,"ZINC, SERUM REF",,84630,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9384630,ZINC REF,,84630,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380430,"C-PEPTIDE, S REF",,84681,301,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9384681,C-PEPTIDE REF,,84681,301,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9380521,"HCG, TOTAL-2ND TRIM QUAD SCRN REF",,84702,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9384701,HCG TEST REF,,84702,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9384702,"GONADOTROPIN, CHORIONIC (HCG)",,84702,301,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9384130,"OSMOLALITY, FECES REF",,84999,301,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9380100,"PHENOLPHTHALEIN, STOOL",,84999,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382466,"CHOLESTROL, BODY FLUID",,84999,301,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9383931,"OSMOLALITY, STOOL",,84999,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9383932,OSMOLALITY -BODY FLUID,,84999,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9384132,POTASSIUM BODY FLUID,,84999,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9385360,EUGLOBULIN CLOT LYSIS TIME REF,,85360,301,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,9386392,IMMUNE COMPLEX ASSAY REF,,86332,301,$97.00 ,$97.00 ,$27.16 ,$88.76 ,$67.90 ,$81.19 ,$88.76 ,$88.76 ,$88.76 ,$35.74 ,$58.20 ,$29.10 ,$87.30 ,$72.75 ,$77.60 ,$80.51
Hoopeston Regional Hlth Center,9380522,CEA (VISTA),,82378,301,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9386352,CELLULAR FUNCTION ASSAY REF,,86352,301,$540.00 ,$540.00 ,$151.20 ,$494.10 ,$378.00 ,$451.98 ,$494.10 ,$494.10 ,$494.10 ,$198.99 ,$324.00 ,$162.00 ,$486.00 ,$405.00 ,$432.00 ,$448.20
Hoopeston Regional Hlth Center,9386619,MULTI USE(MISCELLANEOUS TEST),,86619,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9388263,CHROM ANALY;45 CELL CT REF,,88263,301,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,9388274,MOL HYB INTPH 25-99CELLS REF,,88274,301,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9388355,"MORPHOMETRIC ANALY, SKEL MUSC.",,88355,301,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9388387,MACROSCOPIC PREP/TISSUE(REF),,88387,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9381443,NBS-GALACTOSEMIA SCRN REF,,82776,301,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9381445,NBS-LSD SCRN REF,,83798,301,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,9381458,DHEA SULFATE,,82626,301,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9381461,IMMUNOGLOBULIN E (IGE),,82785,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9381462,INSULIN,,83525,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9381463,C-PEPTIDE,,84681,301,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380229,GASTRIC OCCULT BLOOD,,82271,301,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9380230,"PREG, QUAL-SERUM",,84703,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9381474,DANTROLENE REF,,80369,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9082962,GLUCOSE BLOOD TEST,,82962,301,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381513,ALANINE AMINO (ALT)(SGOT) REF,,84460,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9381477,"A1AT PROTEOTYPE S/Z, LC-MS/MS REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381487,"HEMOSIDERIN, U REF",,83070,301,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381488,"NICKEL, RANDON, U REF",,83885,301,$98.00 ,$98.00 ,$27.44 ,$89.67 ,$68.60 ,$82.03 ,$89.67 ,$89.67 ,$89.67 ,$36.11 ,$58.80 ,$29.40 ,$88.20 ,$73.50 ,$78.40 ,$81.34
Hoopeston Regional Hlth Center,9380231,"IONIZED CALCIUM, ISTAT",,82330,301,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9380232,"BLOOD GASES, ISTAT G3 PLUS",,82803,301,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,9383593,"KETOSTEROIDS, 17 FRACT REF",,83593,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9383664,LAMELLAR BODY DENSITY REF,,83664,301,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9383681,MANGANESE REF,,83785,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9380274,"GONADOTROPIN, CHORIONIC (HCG) REF",,84702,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9380273,ARSENIC REF,,82175,301,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9380283,CARBON DIOXIDE (BICARBONATE) REF,,82374,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381530,"AMMONIUM, 24 HR, U REF",,82140,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9381531,"UREA NITROGEN, U REF",,84540,301,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9380628,"PSA, DIAGNOSTIC (VISTA)",,84153,301,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9380629,"PSA, SCREENING (VISTA)",,G0103,301,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,8282962,GLUCOSE BLOOD TEST,,82962,301,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9381524,THIOPURINE METABOLITES (PROMETHEUS) REF,,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381525,TPMT ENZYME (PROMETHEUS) REF,,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381535,NBS-AMINO/FATTY/ORGANIC ACIDS SCRN REF,,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381537,"COENZYME Q10, RED AND TOT, P REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381093,ACH RECEPTOR (MUSCLE) MOD AB-RFLX REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381538,"10 DRUG PANEL, URINE",,80307,301,$940.00 ,$940.00 ,$263.20 ,$860.10 ,$658.00 ,$786.78 ,$860.10 ,$860.10 ,$860.10 ,$346.39 ,$564.00 ,$282.00 ,$846.00 ,$705.00 ,$752.00 ,$780.20
Hoopeston Regional Hlth Center,9381542,"VIT B12 BINDING CAPACITY, UNSAT REF",,82608,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9381543,"CARBON MONOXIDE, B REF",,82375,301,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9382108,"ALUMINIM, SERUM REF",,82108,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9380188,PRIMIDONE REF,,80188,301,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,8282270,"G BLOOD OCCULT,BY PEROXID,FECES,SINGLE, COLORECTAL SCREEN",,82270,301,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,9381557,"METHEMOGLOBIN, B REF",,83050,301,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9381556,"SULHEMOGLOBIN, B REF",,83060,301,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9381563,"CEA, PANCREATIC CYST REF",,82378,301,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9381565,SOLUBLE TRANSFERRIN RECEPTOR REF,,84238,301,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9381566,"TC (TRIIODOTHYRONINE), REVERSE REF",,84482,301,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,9381572,CMP REF,,80053,301,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9381575,BMP REF,,80048,301,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,9380637,PROCALCITONIN REF,,84145,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,8381579,"IMMUNOGLOBULIN M (IGM), S REF",,82784,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9381580,GAMMAGLOBULIN IGA/IGD/IGG/IGM,,82784,301,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381590,"GALACTOSEMIA REFLEX, B REF",,82775,301,$84.00 ,$84.00 ,$23.52 ,$76.86 ,$58.80 ,$70.31 ,$76.86 ,$76.86 ,$76.86 ,$30.95 ,$50.40 ,$25.20 ,$75.60 ,$63.00 ,$67.20 ,$69.72
Hoopeston Regional Hlth Center,9381598,DRUG SCREEN AMPHETAMINES 1/2 REF,,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381591,"CALPROTECTIN, FECAL",,83993,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9381602,DRUG SCREEN CLASS LIST A REF,,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381603,ACETAMINOPHEN REF,,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381594,"MEPHEDRONE, MDPV, METHYLONE REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,8284295,ASSAY OF SERUM SODIUM,,84295,301,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9381607,"THROMBIN-ANTITHROMBIN COMPLEX, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381609,PROTHROMBIN FRAGMENT 1+2 REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381611,LYSOMAL ENZYME SCREEN/GAUCHER'S REF,,82963,301,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9381612,"CORTICOSTERONE QUANT, S REF",,82528,301,$90.00 ,$90.00 ,$25.20 ,$82.35 ,$63.00 ,$75.33 ,$82.35 ,$82.35 ,$82.35 ,$33.17 ,$54.00 ,$27.00 ,$81.00 ,$67.50 ,$72.00 ,$74.70
Hoopeston Regional Hlth Center,9380652,GALACTOKINASE B REF,,82759,301,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380678,"SEROTONIN, URINE REF",,84260,301,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9380679,OLIGOSACCHARIDES REF,,84375,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9381621,"HYPOGLYCEMIC AGENT SCREEN, S REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381623,"SYNTHETIC CANNAB METAB SCR, EXP, U REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381627,VOLATILES REF,,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381628,"ETHYL GLUCURONIDE CONFIRM, U REF",,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381629,"QUETIAPINE (SEROQUEL), SERUM REF",,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381630,"THYROGLOBULIN, FNA, LYMPH NODE REF",,84432,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9381635,"ANTIDEPRESSANTS CLASS 3-4, REF",,80333,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9381638,"HYPOGLYCEMIC AGENT SCREEN, S, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381641,"MEPHEDRONE, MDPV, METHYLONE, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381645,"CONFIRMED DRUG ABUSE PANEL 9, U, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381649,"FENTANYL SCREEN, U, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381650,"ASSAY OF LIPOPROTEIN, REF",,83718,301,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9381647,"INFLIXIMAB QN WITH REFLEX TO AB, S, REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9381648,"INFLIXIMAB AB, S, REF",,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9381652,"PAIN CLINIC IMMUNOASSAY PANEL, U, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381651,"RNA POLYMERSE III AB, IGG, S, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381656,"PH, FECAL, REF",,83986,301,$14.00 ,$14.00 ,$3.92 ,$12.81 ,$9.80 ,$11.72 ,$12.81 ,$12.81 ,$12.81 ,$5.16 ,$8.40 ,$4.20 ,$12.60 ,$10.50 ,$11.20 ,$11.62
Hoopeston Regional Hlth Center,9381657,"MUCOPOLYSACCARIDES (MPS), QL, U, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381660,"IODINE, S, REF",,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9380993,AMIKACIN LEVEL,,80150,301,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9381664,"CYCLIC AMP, URINARY EXCRETION, REF",,83020,301,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9381667,"LYSOSOMAL/PEROXISOMAL, BS, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381569,"GLUCOPSYCHOSINE, BS, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381670,"HEPATITIS B SURFACE AG, QN, MONITORING, REF",,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9381671,"AMPHETAMINES, REF",,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381676,"FATTY ACID PROFILE, ESSENTIAL, S, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381677,"WB ANTI-RETINAL AUTO-ABS, REF",,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9381683,"VGKC COMPLEX AB IPA, CSF, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381684,"GANGLIOSIDE AB PANEL, SER, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381690,"68KD (HSP-70) ANTIBODIES, REF",,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9381697,"AMYLASE, BF, REF",,82150,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9381708,"N-METHYLHISTAMINE, U, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381709,"TSH, SENSITIVE, S, REF",,84443,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9381712,"SENSORIMOTOR NEUROPATHY, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381713,"IFN-Y, SERUM, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381714,"LEPTIN, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381716,"TUMOR NECROSIS FACTOR, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381717,"EOSINOPHIL CATIONIC PROTEIN, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381718,"ADENOSINE DEAMINASE PLEURAL FLUID, REF",,84311,301,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381719,"IMMUNOASSAY NONANTIBODY, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381723,"MATRIX METALLOPROTEINASE 9, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381722,"HLA DRB3,4,5 LOW RESOLUTION, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381724,"HUMAN TRANSFORMING GROWTH FACTOR BETA 1, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381725,"ACTIN (SMOOTH MUSCLE) ANTIBODY, IGG, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381619,"PROTEIN ELECTROPHORESIS, U, REF",,84166,301,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9381618,"PROTEIN TOTAL, U, REF",,84156,301,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9381731,"IL 2 RECEPTOR (SOLUBLE) BY MAFD, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381729,"INTERLEUKIN 6, P",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381730,"ANTI-GMCSF/IFNG AB, ELISA, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381703,"PROSTATE SPECIFIC ANTIGEN, S",,84153,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381704,"FREE PSA, S",,84154,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381736,"OXYGEN DISSOCIATION P50, REF",,82820,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9381738,"PLASMA HEMOGLOBIN, PLASMA REF",,83051,301,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9381744,"IODINE, 24 HR, U, REF",,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381740,"ASSAY OF SERUM ALBUMIN, REF",,82040,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381741,"OTHER SOURCE ALBUMIN QUAN EA, REF",,82042,301,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9381743,"ASSAY IGA/IGD/IGG/IGM EACH, REF",,82784,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9381749,"INSULIN-LIKE GROWTH FACTOR II, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381758,"ADMARK PHOSPHO TAU/TOTAL TAU/A BETA 42 CSF ANAL AND INTER, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381759,"CEREBROTENDINOUS XANTHOMATOSIS, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381761,"IMMUNOGLOBULIN A (IGA), S",,82784,301,$37.00 ,$37.00 ,$10.36 ,$33.86 ,$25.90 ,$30.97 ,$33.86 ,$33.86 ,$33.86 ,$13.63 ,$22.20 ,$11.10 ,$33.30 ,$27.75 ,$29.60 ,$30.71
Hoopeston Regional Hlth Center,9381762,"ALPHA-GALACTOSIDASE, LEUKOCYTES, REF",,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9381773,"DESMOGLEIN 1 AND 3, S, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381774,"ALCOHOL BIOMARKERS, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381775,"ANTI-HMGCR AB, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380999,THROMBOPOIETIN (TPO) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,8282803,"BLOOD GASES: PH, PO2 & PCO2",,82803,301,$410.00 ,$410.00 ,$114.80 ,$375.15 ,$287.00 ,$343.17 ,$375.15 ,$375.15 ,$375.15 ,$151.09 ,$246.00 ,$123.00 ,$369.00 ,$307.50 ,$328.00 ,$340.30
Hoopeston Regional Hlth Center,9381034,"PSA, ULTRASENSITIVE REF",,84153,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9382239,"BILE ACIDS, TOTAL REF",,82239,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9381043,"OXALATE, PLASMA REF",,83945,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9381045,"APOLIPOPROTINE B, S REF",,82172,301,$84.00 ,$84.00 ,$23.52 ,$76.86 ,$58.80 ,$70.31 ,$76.86 ,$76.86 ,$76.86 ,$30.95 ,$50.40 ,$25.20 ,$75.60 ,$63.00 ,$67.20 ,$69.72
Hoopeston Regional Hlth Center,9381046,"HDL CHOLESTEROL, CDC, S REF",,83718,301,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9381776,"PROTOPORPHYRINS, FRACTIONATION, WB, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381777,"BLD UREA NITROG, BF, REF",,84520,301,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9381783,"HEXOSE TETRASACCHARI/HEX4, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381086,PSEUDOCHOLIN.DIB.INHIB. REF,,82638,301,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9381087,"T3 (TRIIODOTHYRONINE), FREE",,84481,301,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9381096,SULFOCYSTEINE ASSAY URINE,,82127,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9381095,HUMAN ANTI-MOUSE (HAMA) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381106,HYPERGLYCOSYLATED HCG (H HCG) REF,,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9381107,VASCULAR ENDOTHEIAL GROWTH FACTOR D (VEGF-D) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,8084112,AMNISURE,,84112,301,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,8082947,BLOOD GLUCOSE LEVEL,,82947,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,8084295,SODIUM,,84295,301,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,8084132,POTASSIUM,,84132,301,$82.00 ,$82.00 ,$22.96 ,$75.03 ,$57.40 ,$68.63 ,$75.03 ,$75.03 ,$75.03 ,$30.22 ,$49.20 ,$24.60 ,$73.80 ,$61.50 ,$65.60 ,$68.06
Hoopeston Regional Hlth Center,8084484,ISTAT TROPONIN,,84484,301,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,8082270,OCCULT BLOOD - FECES,,82270,301,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,9381118,"NEURON SPECIFIC ENOLASE, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381126,"GLUCOSE PHOSPHATE ISOMER, REF",,84087,301,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9381784,"AMPHETAMINES CONFIRMATION, REF",,80324,301,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381785,"METHYLENEDIOXYAPHETAMINES, REF",,80359,301,$40.00 ,$40.00 ,$11.20 ,$36.60 ,$28.00 ,$33.48 ,$36.60 ,$36.60 ,$36.60 ,$14.74 ,$24.00 ,$12.00 ,$36.00 ,$30.00 ,$32.00 ,$33.20
Hoopeston Regional Hlth Center,9381786,"COCAINE AND METABOLITE CONF, REF",,80353,301,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9381787,"OPIATES 1 OR MORE, REF",,80361,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9381788,"OXYCODONE, REF",,80365,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9381782,"CARBOXY-THC CONFIRMATION, REF",,80349,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9381793,HEMOGLOBIN ELECTROPHORESIS,,83020,301,$70.00 ,$70.00 ,$19.60 ,$64.05 ,$49.00 ,$58.59 ,$64.05 ,$64.05 ,$64.05 ,$25.80 ,$42.00 ,$21.00 ,$63.00 ,$52.50 ,$56.00 ,$58.10
Hoopeston Regional Hlth Center,9381797,"NEOPTERIN, SERUM, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381796,BILLING BENZENE CPT 82570-90,,82570,301,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9381798,"CREATININE CONC, REF",,82570,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9381801,"GLUCOTETRASACCHARIDES, U, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381806,"CALCIUM, IONIZED",,82330,301,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9381131,"MAGNESIUM, RBC REF",,83735,301,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381132,"PHOSPHORUS (INORGANIC), S REF",,84100,301,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381133,TUBULAR PHOSP REABSORP RDM REF,,84105,301,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9381143,"INTERLEUKIN-6 (IL-6), S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381144,"HISTONE AUTOANTIBODIES, S REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381141,"C1 ESTERASE INHIBITOR AG, S REF",,83883,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9381142,"C1 ESTERASE INHIB, FUNCTIONAL ASSAY, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381808,"CHYMOTRIPSIN, STOOL, REF",,84311,301,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381814,"BETA-GLUCOSIDASE, LEUKOCYTES, REF",,82963,301,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9381815,"ADMA/SDMA, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381822,"RNA POLYMERASE III AB, IGG, S, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381823,"BILIRUBIN DIRECT, FLUID, REF",,82248,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9381819,"(CSF) 14-3-3, REF CASE WESTERN",,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9381825,"BP 180 AND 230, S, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381826,"PAI-1 ANTIGEN, REF",,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9381827,"PORPHOBILINOGEN DEAMINASE (PBGD), WHOLE BLOOD, REF",,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9381828,"TETRAHDROBIOPTERIN AND NEOPTERINE PROFILE, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381831,"PORPHOBILINOGEN, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381829,"TESTOSTERONE, FREE, S, REF",,84402,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9381830,"TESTOSTERONE, BIOAVAIL, S REF",,84410,301,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9381197,"FRATAXIN, QUANT, WB REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381836,"REDUCING SUBSTANCE, FECES, REF",,84376,301,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9381837,"SMITH-LEMLI-OPITZ SCREEN, PLASMA REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381845,"S100B, CSF, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381843,"CYSTINURIA PROFILE, QN, 24 HR, REF",,82136,301,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9381850,"ACYLGLYCINES, QUANT, URINE, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381852,"DIURETIC SCREEN, URINE REF",,80377,301,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9381851,ASSAY OF PROGESTERONE REF,,83498,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9381860,"BETA AMYLOID RATIO, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381861,"HMG-COA ELISA, S, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381863,"ALPHA SUBUNIT PITUITARY TUMOR MARKER, REF",,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9381864,"BETA-HCG QUANTITATIVE, S, REF",,84702,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9381866,"ALPHA AMINO ADIPIC SEMIALDEHYDE, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381867,"DIHYDROTESTOSTERONE, S, REF",,82642,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9381872,"5-METHYLTETRAHYDROFOLATE, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381876,"NEUROTENSIN, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381881,"VEDOLIZUMAB QN, S, REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9381882,"VEDOLIZUMAB AB, S, REF",,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9381879,ADMARK PHOSPHO-TAU/TOTAL-TAU/A BETA 42,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381887,"ADALIMUMAB QN WITH REFLEX TO AB, S, REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9381888,"GLOM BASEMENT MEMBRANE AB, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381889,SAA (SERUM AMYLOID A) (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381890,IL-7 (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381891,ANG-1 (ANGIOPOIETIN-1) (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381892,ANG-2 (ANGIOPOIETIN-2) (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381893,CEACAM-1 (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381894,"TGF ALPHA, (PROMETHEUS) REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381895,MMP-1 (COLLAGENASE ENZYME) (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381896,MMP-2 (GELATINASE ENZYME) (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381897,MMP-3 (STROMELYZIN ENZYME) (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381898,MMP-9 (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381899,EMMPRIN (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381900,VCAM (PROMETHEUS) REF,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381901,"MITOCHONDRIAL AB, M2, S, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381903,"VOLTAGE-GATED CALCIUM CHANNEL (VGCC), AB, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381905,"HMGCR ANTIBODY, IGG, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381906,"3-O-METHYLDOPA, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381907,"PALIPERIDONE, SERUM, REF",,80342,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9381911,"METHYLENE CHLORIDE/TETRACHLOROETHYLENE, BL, REF",,82441,301,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9381912,"RACOMBX MATA AUTOANTIBODY TEST, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381918,"M. PNEUMONIAE AB, IGM, S BY IFA, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381919,"COPEPTIN PRO-AVP, P, REF",,84588,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9381915,"OSMOLALITY, URINE, REF",,83935,301,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381920,"PHOSPHATIDYLETHANOL (PETH), REF",,80321,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9381922,"LYSOSOMAL AND PEROXISOMAL STORAGE DISORDER SCREEN, REF",,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381925,"PROCOLLAGEN I INTACT N-TERMINAL, SERUM, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381927,"RHEUMATOID FACTORS IGA, IGG, AND IGM BY ELISA, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381928,"ACETYLCHOLINE MODULATING AB, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381937,"B-TYPE NAT PEPTIDE (BNP) S, REF",,83880,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9381938,"LEPTIN, REF",,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9381947,"OXALATE, SERUM/PLASMA REF",,83945,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9381948,"MELANOCYTE STIMULATING HORMONE, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381958,"CO GM1 QUATTRO, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381957,"GALACTOSE 4 EPIMERASE, BLOOD, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381955,"FLUORESCENT AB TITER, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381953,"LSD CONFIRMATION, U, REF",,80323,301,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9381960,"LP (A) CHOLESTEROL, REF",,83700,301,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9381962,"MI-2, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381965,"INTERLEUKIN 2, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381967,"IGG MONOS GM1 TITER, S, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381970,"STEROLS, PLASMA, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381981,"CANNABINOID/CREATININE RATIO, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381983,"LEUKOTRIENE E4, URINE, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9381985,"MYELIN ASSOC. GLYCOPROTEIN (MAG) AB, IGM, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381991,"MANNOSE BINDING LECTIN, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381994,"LACOSAMIDE S, REF",,80235,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9381997,"BUPRENORPHINE, URINE, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9382186,"IGA ALLERGEN, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382188,"SLA AUTOANTIBODY, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382190,"VORICONAZOLE, S, REF",,80285,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9382204,"F2 ISOPROSTANES, RANDOM, URINE, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382211,"ANTI-IGA, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382212,"INFLIXIMAB QANT W/REFLEX TO AB TO INFILXIMAB, S, REF",,80230,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9382302,"OXIDIZED LDL, REF",,83721,301,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9382344,"Hc Posaconazole, S, Ref",,80187,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9382361,"PAPPA SERUM, REF",,84163,301,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9382362,"HCG FREE BETACHAIN TEST, REF",,84704,301,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9382368,SARS-COV-2 IGG,,86769,301,$93.00 ,$93.00 ,$26.04 ,$85.10 ,$65.10 ,$77.84 ,$85.10 ,$85.10 ,$85.10 ,$34.27 ,$55.80 ,$27.90 ,$83.70 ,$69.75 ,$74.40 ,$77.19
Hoopeston Regional Hlth Center,9382367,"SUCCINYLACETONE, BS, REF",,83789,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382371,"DHEA-SULFATE, REF",,82627,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382375,"VITAMIN E, REF",,84446,301,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9382417,"2,3-DINOR-11 BETA-PROSTAGLANDIN F2 ALPHA, U, REF",,84150,301,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9382424,"ALPHA GLOBIN GENE SEQ, B, REF",,81259,301,"$2,400.00 ","$2,400.00 ",$672.00 ,"$2,196.00 ","$1,680.00 ","$2,008.80 ","$2,196.00 ","$2,196.00 ","$2,196.00 ",$884.40 ,"$1,440.00 ",$720.00 ,"$2,160.00 ","$1,800.00 ","$1,920.00 ","$1,992.00 "
Hoopeston Regional Hlth Center,9382426,"21-HYDROXYLASE AB, S, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9382428,"5-FLUCYTOSINE, S, REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382430,"HMG-COA REDUCTASE AB, S, REF",,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9382431,"TITANIUM, S, REF",,83018,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9382441,"MECONIUM DRUG SCREEN, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9382445,"PLAZOMICIN, PLASMA, REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382446,"BETA-GALACTOSIDASE, LEUKOCYTES, REF",,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382447,"METHAQUALONE, S/P, REF",,80368,301,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9382449,"PANCREATIC ELASTASE, F REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383721,DIRECT LDL,,83721,301,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9382450,"IODINE, S/P REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382452,"HEPATITIS B SURFACE AG, QN MONT, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382455,"CHYLOMICRON SCREEN, BF, REF",,82664,301,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9382458,"SOLUBLE CD163 ASSAY, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382460,"ANTI-PM/SCL-100 AB, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382461,"ADALIMUMAB QN W/REFLEX TO AB, S, REF",,80145,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9382462,"IGF BINDING PROTEIN-1, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9382463,"THIOPURINE METHYLTRANSFERACE ACTIVITY PROFILE, REF",,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382469,"COPPER, RBC",,82525,301,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9382471,INHIBIN B,,82397,301,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9382472,TSH RECEPTOR BINDING AB,,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382474,"VITAMIN B6, REF",,84207,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9382483,"CHOLESTEROL PLEURAL FLUID, REF",,84311,301,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9382491,"MYOSITIS SPECIFIC 11 AB PANEL, REF",,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9382498,"SUCCINYLACETONE, QUANT, UR, REF",,83921,301,$85.00 ,$85.00 ,$23.80 ,$77.78 ,$59.50 ,$71.15 ,$77.78 ,$77.78 ,$77.78 ,$31.32 ,$51.00 ,$25.50 ,$76.50 ,$63.75 ,$68.00 ,$70.55
Hoopeston Regional Hlth Center,9382479,"SEX HORMONE BINDING GLOBULIN, S",,84270,301,$87.00 ,$87.00 ,$24.36 ,$79.61 ,$60.90 ,$72.82 ,$79.61 ,$79.61 ,$79.61 ,$32.06 ,$52.20 ,$26.10 ,$78.30 ,$65.25 ,$69.60 ,$72.21
Hoopeston Regional Hlth Center,9382529,"OPIATES, GC/MS, U REF",,80361,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9382531,"ADALIMUMAB AB, IBD",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382532,"ADALIMUMAB LEVEL, IBD",,80145,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9382545,"METALLOPROTEINASE-7, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9382547,"MOTOR NEUROPATHY PROFILE, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382577,"GANGLIOSIDE AB PANEL, SER, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9382582,"RETINOL BINDING PROTEIN, REF",,83883,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9382522,"PTH RELATED PROTEIN, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9383533,"RIBOSOMAL P AB, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9382584,CARBOXYHEMOGLOBIN,,82375,301,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9382586,"ANTI-TH/TO AB, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9382588,"GONADOTROPIN RELEASING HORMONE, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382590,"ALPHA-MANNOSIDASE, LEUKOCYTES, REF",,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382594,"ALPHA MELAOCYTE STIMULATING HORMONE, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382598,"PHOSPHATIDYLETHANOL, REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382603,"THIOPURINE METABOLITES, REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382610,"CHEMISTRY PROCEDURE (MOTOR NEURO PANEL), REF",,84160,301,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9382551,"PANCREATIC ELASTASE-1, FECAL",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382580,"RHEUMATOID FACTOR, IGG, S REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382612,"CENOBAMATE (XCOPRI), PLASMA, REF",,80299,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382613,"THYMIDINE DETERMINATION, PLASMA REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382504,"H. PYLORI UREA BREATH TEST, REF",,83013,301,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9382616,"TRAB Ab, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382617,"ANTIDIURETIC HORMONE PROFILE, REF",,84588,301,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9382618,"ANTI-CN-1A (NT5C1A) IBM (RDL), REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382666,"PURINES AND PYRIMIDINES PANEL, P, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382667,"RUFINAMIDE, SERUM, REF",,80210,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9382669,"CARB-10, 11-EPOXIDE, S, REF",,80161,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382671,"LIVER FIBROSIS, FIBROMETER, REF",,83883,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9382675,"LIVER FIBROSIS, FIBROSIS METAVIR, REF",,84460,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382684,"PHOSPHOLIPASE A2 RECEPTOR ELISA, S, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382685,"CARBOHYDRATE, U, REF",,84377,301,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9382506,"TRYPTASE, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382680,"LIVER FIBROSIS, INFLAMETER METAYIR, REF",,84520,301,$16.00 ,$16.00 ,$4.48 ,$14.64 ,$11.20 ,$13.39 ,$14.64 ,$14.64 ,$14.64 ,$5.90 ,$9.60 ,$4.80 ,$14.40 ,$12.00 ,$12.80 ,$13.28
Hoopeston Regional Hlth Center,9382763,"OX LDL, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382765,"MULTIPLE SCLEROSIS PROFILE, REF",,83883,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9382766,"VWF COLLAGEN BINDING, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382759,"ANGIOTENSIN CONVERTING ENZYME, CSF REF",,82164,301,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9382769,"LAMOTROGINE, S, REF",,80175,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9382771,"PORPHOBILINOGEN, P, REF",,82542,301,$97.00 ,$97.00 ,$27.16 ,$88.76 ,$67.90 ,$81.19 ,$88.76 ,$88.76 ,$88.76 ,$35.74 ,$58.20 ,$29.10 ,$87.30 ,$72.75 ,$77.60 ,$80.51
Hoopeston Regional Hlth Center,9382776,"AMYLASE, ISOENZYMES, REF",,82150,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9382779,"FLECAINIDE, S, REF",,80181,301,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9382785,"CYCLOSPORINE A TROUGH, B [REF]",,80158,301,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382781,"PREGNENOLONE, S [REF]",,84140,301,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9382782,"DEXAMETHASONE, S [REF]",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382773,"LACTIC ACID, CSF [REF]",,83605,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9382774,"SODIUM, 24-HOUR URINE",,84300,301,$20.00 ,$20.00 ,$5.60 ,$18.30 ,$14.00 ,$16.74 ,$18.30 ,$18.30 ,$18.30 ,$7.37 ,$12.00 ,$6.00 ,$18.00 ,$15.00 ,$16.00 ,$16.60
Hoopeston Regional Hlth Center,9382388,"Bile Acids, Bowel Dysfunction, 48 Hr, Feces, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382411,"Alcohol (Ethanol), REF",,82077,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382796,"MUSK ANTIBODY, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9382473,"CPT- CREATININE, URINE",,82570,301,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382503,"CPT-PROTEIN TOTAL, URINE",,84156,301,$15.00 ,$15.00 ,$4.20 ,$13.73 ,$10.50 ,$12.56 ,$13.73 ,$13.73 ,$13.73 ,$5.53 ,$9.00 ,$4.50 ,$13.50 ,$11.25 ,$12.00 ,$12.45
Hoopeston Regional Hlth Center,9382507,CPT-ELECTROPHORETIC FRACTIONATION,,84166,301,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9382508,"CARNITINE, S [REF]",,82379,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382509,"CARNITINE, U [REF]",,82379,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9382510,"PROLACTIN, DILUTION STUDY, S [REF]",,84146,301,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9382512,SELENIUM REF,,84255,301,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9382801,"DHR Flow fMLP, B, REF",,86352,301,$545.00 ,$545.00 ,$152.60 ,$498.68 ,$381.50 ,$456.17 ,$498.68 ,$498.68 ,$498.68 ,$200.83 ,$327.00 ,$163.50 ,$490.50 ,$408.75 ,$436.00 ,$452.35
Hoopeston Regional Hlth Center,9382803,"ITRACONAZOLE, S, REF",,80189,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9382807,"HEMOQUANT, FECES [REF]",,84311,301,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9382805,"THYROGLOBULIN, CHEMILUMINESCENT, B [REF]",,84432,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9382806,"THYROGLOBULIN, LC/MS/MS, B [REF]",,84432,301,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9382812,"ITRACONAZOLE, B [REF]",,80189,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9382821,"INSULIN-LIKE GROWTH FACTOR-BINDING PROTEIN-1, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382829,"INSULIN, FREE AND TOTAL, S, REF",,83527,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9382831,"AUTOIMMUNE DYSAUTONMIA EVAL, S, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9382828,CYROGLOBULIN SCREEN W/RFX TO PANEL,,82595,301,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9382819,"CALCITONIN, B [REF]",,82308,301,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9382832,"THIOPURINE METHYLTRANSFERASE ACTIVITY PROFILE, ERYTH, REF",,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382817,"INFLIXIMAB AB, IBD",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382818,INFLIXIMAB LEVEL,,80230,301,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9382834,"DRUG MONITOR, PANEL 1 W/CONFIRM, U",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9382855,"PSYCHOSINE, WHOLE BLOOD, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9382878,"INTERLEUKIN-4, S, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382970,"DM, ALCOHOL METABOLITE W/CONFIRM, U [REF]",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9382969,"LACTIC ACID, B [REF]",,83605,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9382966,"HUMAN TRANSFORM GROWTH FACT. BETA 1 (TGF-B1), B [REF]",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382967,"14.3.3 ETA PROTEIN, B [REF]",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382975,"INTERLEUKIN 17, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9382978,"INTERLEUKIN 1-BETA, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383067,"RAJI CELL IMMUNE COMPLEX, REF",,86332,301,$97.00 ,$97.00 ,$27.16 ,$88.76 ,$67.90 ,$81.19 ,$88.76 ,$88.76 ,$88.76 ,$35.74 ,$58.20 ,$29.10 ,$87.30 ,$72.75 ,$77.60 ,$80.51
Hoopeston Regional Hlth Center,9382981,"HISTONE AUTOANTIBODIES, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383078,"ESTADIOL RESPONSE, REF",,80415,301,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9383082,"GLUTEN SENSITIVITY SCREEN, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383108,"KAPPA/LAMBDA LIGHT CHAIN, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383113,"MYOMARKER 3 PROFILE, REF",,83516,301,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9383115,"BETA-HYDROXYBUTYRATE, S, REF",,82010,301,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9383109,"BULLOUS PEMPHIGOID AB, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383123,"ESTRADIOL, SERUM, REF",,82670,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9383134,"LIVER CYTOSOLIC ANTIGEN TYPE 1 IGG, REF",,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9383135,"N-METHYL-D-ASPARTATE RECEPTOR AB, CSF, REF",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9383138,"INTERLEUKIN 13, S, REF",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383142,"FREE ESTRADIOL, SERUM, REF",,82681,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9383143,"PHOSPHOFRUCTOKINASE ENZYME ACTIVITY, BL, REF",,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9383146,"TESTOSTERONE,F/WKLYBD+T LC/MS, REF",,84410,301,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9383148,"ADENYLATE KINASE ENZYME ACTIVITY, BL, REF",,82657,301,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9383149,"PSA, ULTRASENSITIVE, REF",,84153,301,$73.56 ,$73.56 ,$20.60 ,$67.31 ,$51.49 ,$61.57 ,$67.31 ,$67.31 ,$67.31 ,$27.11 ,$44.14 ,$22.07 ,$66.20 ,$55.17 ,$58.85 ,$61.05
Hoopeston Regional Hlth Center,9383163,"LUPUS ANTICOAG EVAL, REF",,85613,301,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,9383166,"NOREPINEPHRINE, PL, REF",,82542,301,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9383170,"CYSTATIN C W/ GFR, B [REF]",,82610,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9383161,"THALLIUM, B [REF]",,83018,301,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9383159,"HMCGR ANITBODY (IGG), B [REF]",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383171,"VOLTAGE-GATED CALCIUM CHANNEL (VGCC) TYPE P/Q AB, B [REF]",,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9383172,"VITAMIN B3, B [REF]",,84591,301,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9383174,"WESTERN BLOT W/ INTERP, EACH",,84182,301,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9383177,"CARNITINE, RANDOM, U, REF",,82379,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9383178,"INTACT FIBROBLAST GROWTH FACTOR 23, S",,83520,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9383184,"CORTISOL, FREE SERUM, REF",,82530,301,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9383185,"DRUG MONTIOR OPIATES, REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9383188,"CHLAMYDIA TRACHOMATIS AG, DFA, REF",,87270,301,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,8282043,"MICROALBUMIN, URINE, QUANT",,82043,301,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,8280307,DRUG TST PRSMV INSTRMNT CHEM ANALYZERS PR DATE,,80307,301,$820.00 ,$820.00 ,$229.60 ,$750.30 ,$574.00 ,$686.34 ,$750.30 ,$750.30 ,$750.30 ,$302.17 ,$492.00 ,$246.00 ,$738.00 ,$615.00 ,$656.00 ,$680.60
Hoopeston Regional Hlth Center,9381204,TRYPSIN-LIKE IMMUNOREACTIVITY REF,,83519,301,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9381218,GONAD RELEASING HORMONE REF,,83727,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381249,"ALCOHOL EMPLOYMENT, URINE REF",,80307,301,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9381258,ALCOHOL REF,,G0480,301,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381248,"ALCOHOL, SERUM",,80307,301,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,82330,"ASSAY OF CALCIUM, IONIZED",,82330,301,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,82435,ASSAY OF BLOOD CHLORIDE,,82435,301,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,82565,ASSAY OF CREATININE,,82565,301,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,82947,"ASSAY QUANTITATIVE,BLOOD GLUCOSE",,82947,301,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,83655,ASSAY OF LEAD,,83655,301,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,84132,ASSAY OF SERUM POTASSIUM,,84132,301,$44.00 ,$44.00 ,$12.32 ,$40.26 ,$30.80 ,$36.83 ,$40.26 ,$40.26 ,$40.26 ,$16.21 ,$26.40 ,$13.20 ,$39.60 ,$33.00 ,$35.20 ,$36.52
Hoopeston Regional Hlth Center,84295,ASSAY OF SERUM SODIUM,,84295,301,$44.00 ,$44.00 ,$12.32 ,$40.26 ,$30.80 ,$36.83 ,$40.26 ,$40.26 ,$40.26 ,$16.21 ,$26.40 ,$13.20 ,$39.60 ,$33.00 ,$35.20 ,$36.52
Hoopeston Regional Hlth Center,84520,"ASSAY UREA NITROGEN, QUAN",,84520,301,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,82272,"BLOOD OCCULT,BY PEROXID, FECES, 1-3 SIMULT, NON CA SCREEN",,82272,301,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,80047,BASIC METABOLIC PANEL CALCIUM IONIZED,,80047,301,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,88720,BILIRUBIN TOTAL TRANSCUTANEOUS,,88720,301,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,G0477,"Pr Drug Test(s), Prsmp, Any Nm Drg Cls/dvcs/prcs Drct Optical Obs Only",,G0477,301,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,80305,DRUG TEST PRSMV READ DIRECT OPTICAL OBS PR DATE,,80305,301,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381417,"FL NONINF AGENT AB; SCRN, EA REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381418,COCCIDIODES REF,,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9386341,ISLET CELL ANTIBODY REF,,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9381439,DENGUE VIRUS NS1 ANTIGEN REF,,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9384060,"PHOSPHATASE, ACID, TOTAL REF",,84060,302,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9386000,AGGLUTININS EACH ANTIGEN REF,,86000,302,$28.00 ,$28.00 ,$7.84 ,$25.62 ,$19.60 ,$23.44 ,$25.62 ,$25.62 ,$25.62 ,$10.32 ,$16.80 ,$8.40 ,$25.20 ,$21.00 ,$22.40 ,$23.24
Hoopeston Regional Hlth Center,9386001,ALLERGEN SPECIFIC IGG,,86001,302,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9380589,FOOD-GRAIN PANEL REF,,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9380590,MOLD PANEL REF,,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9380730,ALLRG SPC IGE QNT/SMQT EA REF,,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9380911,FOOD PANEL REF,,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9380947,FOOD NUT PANEL #1 REF,,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9386003,ALLRG SPC IGE QNT/SMQT EA REF,,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9389500,PATHOLOGY TEST REF,,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9380953,"GRANULOCYTE ABS, S REF",,86021,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9386027,PROTEINASE-3 ANTIBODY REF,,86021,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9386045,MYELOPEROXIDASE ANTIBODY REF,,86021,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9386067,LEUKOCYTE ANTIBODIES REF,,86021,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9380407,PLATELET AB S REF,,86022,302,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9386024,PLATELET ANTIBODIES REF,,86022,302,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9382165,HEPARIN DEPENDENT PLATELET ABS,,86022,302,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9380378,"ANTINUCLEAR AB, S REF",,86038,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386038,ANTINUCLEAR ANTIBDIES(ANA) REF,,86038,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386039,ANTINUCLEAR ANTIBODIES REF,,86038,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386050,ANTINUCLEAR ANTIBODY SCREEN,,86038,302,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,9386064,ANA TITER & PATTERN REF,,86039,302,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9386051,ANTINUCLEAR ANTIBODY PROFILE,,86039,302,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9380763,"ANTISTREP-O TITER, S REF",,86060,302,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9386060,ANTISTREPTOLYSIN O (ASO) TITER,,86060,302,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9380350,C-REACTIVE PROTEIN (SGI-PROMETH),,86140,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9380600,C-REACTIVE PROTEIN REF,,86140,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9386140,C-REACTIVE PROTEIN,,86140,302,$93.00 ,$93.00 ,$26.04 ,$85.10 ,$65.10 ,$77.84 ,$85.10 ,$85.10 ,$85.10 ,$34.27 ,$55.80 ,$27.90 ,$83.70 ,$69.75 ,$74.40 ,$77.19
Hoopeston Regional Hlth Center,9386138,"CRP, HIGH SENSITIVITY",,86141,302,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9380801,"BETA 2 GP1 AB PANEL, S REF",,86146,302,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9386146,"BETA-2 GLYCOPROTEIN,ABS EA REF",,86146,302,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9386147,CARDIOLIPIN ANTIBODIES REF,,86147,302,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9386318,CARDIOLIPIN ANTIBODIES REF,,86147,302,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9380983,ANTI-PHOSPHATIDLYSERINE AB REF,,86148,302,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9386150,COLD AGGLUTININ TITER REF,,86157,302,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9383755,C1 ESTERASE INHIBITOR TOTL REF,,86160,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386159,"COMPLEMENT AG, EACH REF",,86160,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386162,COMPLEMENT C3C REF,,86160,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386163,COMPLEMENT C4C REF,,86160,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386165,COMPLEMENT ANTIGEN REF,,86160,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386160,"COMPLEMENT ANTIGEN, EACH COMP.",,86160,302,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9386166,LUPUS PANEL-COMP C3,,86160,302,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9383545,C1 ESTERSE INHIBITR FUNCTNL RF,,86161,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386161,"COMPLEMENT;AG,FNCTNL ACTIV REF",,86161,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380384,"COMPLEMENT, TOTAL, S REF",,86162,302,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9386164,COMPLEMENT TOTAL (CH50) REF,,86162,302,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9380379,"CYCLIC CITRULL PEPTIDE AB, S REF",,86200,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380742,"CYCLIC CITRULL PEPTIDE AB, S REF",,86200,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9382405,CYCLIC CITRUL PEPTIDE AB REF,,86200,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380764,"ANTI-DNASE B TITER, S REF",,86215,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386215,DNASE-B ANTIBODY REF,,86215,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380380,"DNA DOUBLE-STRANDED AB, IGG, S REF",,86225,302,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9386225,DNA ANTIBODY REF,,86225,302,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9386030,"ANTI-NATIVE DNA AB, IFA",,86225,302,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9380246,DNA SINGLE-STRANDED AB REF,,86226,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382730,"EXTRAC NUCLEAR AG AB, EA REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9380131,CHROMATIN ANTIBODY-EACH AB REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9380707,"SS-A/RO & B/LA AB, IGG, S REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9380925,SCL 70 ANTIBODY REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9380936,SM ABS REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9380937,RNP ABS REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9380938,JO 1 ABS REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9383571,JO-1 ANTIBODY,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9386139,"ENA ANTIBODY, EACH AB REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9386235,SM (SMITH)ANTIBODY-EACH AB REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9386236,ENA ANTIBODY-EACH ANTIBODY REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9386237,SM/RNP ANTIBODY TEST REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9386238,SJOGREN'S ANTIBODY-EACH AB REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9386239,SJOGREN'S ANTIBODY-EACH AB REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9386240,SM ANTIBODY TEST REF,,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9386335,"EXTRACTABLE NUCLEAR AG ANTIBODY, EA REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9386242,"CYTOPLASMIC NEUTROPHILIC AB, S REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386254,"FL NONINF AGENT AB; SCRN, EA REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380454,"CYTOPLASMIC NEUTROPHILIC AB, S REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380973,"SMOOTH MUSCLE ABS, S REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386244,PARIETAL CELL AB SCREEN REF,,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386251,NMO/AQP4-IGG CBA REF,,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386259,RETICULIN ABS REF,,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386272,ENDOMYSIUM AB IGA W/REFLX TTRF,,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386241,LUPUS PANEL-CENTROMERE ANTIBOD,,86255,302,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9386243,LUPUS PANEL-MITOCHONDRIAL AB,,86255,302,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9386245,LUPUS PANEL-RETICULIN ANTIBODY,,86255,302,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9386246,LUPUS PANEL-SKELETAL MUSCLE AB,,86255,302,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9386247,LUPUS PANEL-ANTI-SMOOTH MUSCLE,,86255,302,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9386253,CELIAC DISEASE,,86255,302,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9386265,"FL NONINF AGENT AB; TITER, EA REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380372,"ENDOMYSIAL ABS, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380550,"ANNA-1, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380551,"ANNA-2, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380552,"ANNA-3, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380553,"AGNA-1, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380554,"PCA-1, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380555,"PCA-2, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380556,"PCA-TR, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380557,"AMPHIPHYSIN AB, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380558,"CRMP-5-IGG, S REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386267,PARIETAL CELL AB TITER,,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386273,FLUORESCNT ANTIBDY TITR-EA REF,,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386723,FLUORESCNT ANTIBDY TITR-EA REF,,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386363,FL NONINF AGENT AB TITER,,86256,302,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,9380525,BR CARCINOMA AG(CA 27.29) REF,,86300,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9380964,"CANCER AG 15-3, S REF",,86300,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9386336,"TUMOR AG, CA 27.29 (CHIRON) RF",,86300,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9386337,"TUMOR ANTIGEN, CA 15-3 REF",,86300,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9380446,"CARBOHYDRATE AG 19-9, S REF",,86301,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9383005,"TUMOR ANTIGEN, CA 19-9 REF",,86301,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9380005,"TUMOR ANTIGEN, CA 125 II REF",,86304,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9386274,"TUMOR ANTIGEN, CA 125",,86304,302,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,9380913,CHROMOGRANIN A REF,,86316,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9383006,TUMOR AG OTHR-CHROMOGRANIN REF,,86316,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9386283,TUMOR AG IMMUNOASSAY REF,,86316,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9386393,IMM ASSAY INF AG AB REF,,86317,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9386317,"S.PNEUMO IGG AB,23 SEROTYPES, S REF",,86317,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9386403,PARTICLE AGGLUTINATION SCREEN,,86317,302,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9386338,IMMUNODIFFUSION NOS,,86329,302,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9386634,IMMUNOFIX CRYOGLOBULIN REF,,86334,302,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382168,SERUM ELEPHORESIS,,86334,302,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9386320,"IMMUNOFIXATION/IMMUNOTYPING, SERUM",,86334,302,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9380605,"BETA-2 TRANSFERRIN, BF REF",,86335,302,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9382995,IMMUNOFIXATN ELECTROPHORSS REF,,86335,302,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9382100,OLIGOCLONAL BANDS,,86335,302,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9382156,IMMUNFIX E-PHORSIS/URINE/CSF,,86335,302,$325.00 ,$325.00 ,$91.00 ,$297.38 ,$227.50 ,$272.03 ,$297.38 ,$297.38 ,$297.38 ,$119.76 ,$195.00 ,$97.50 ,$292.50 ,$243.75 ,$260.00 ,$269.75
Hoopeston Regional Hlth Center,9386424,IMMUNOFIXATION ELP -FLUIDS,,86335,302,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9380516,"INHIBIN A, TUMOR MARKER, S REF",,86336,302,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9386158,INHIBIN A REF,,86336,302,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9380418,INSULIN ANTIBODIES REF,,86337,302,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9386386,INSULIN ANTIBODIES REF,,86337,302,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9382792,"INTRINSIC FACTOR BLOCKING AB, S REF",,86340,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9386349,INTRINSIC FACTOR BLOCK AB REF,,86340,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9380565,"GAD65 AB ASSAY, S REF",,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9386255,ISLET CELL ANTIBODY REF,,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9386346,ISLET CELL ANTIBODY TITER REF,,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9386343,LEUCOCYTE HISTAMIN RELEASE,,86343,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9386353,LYMHOCYTE TRANSFORMATION REF,,86353,302,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9386355,B CELLS TOTAL COUNT REF,,86355,302,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9386423,B CELLS TOTAL COUNT,,86355,302,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,9386357,NK CELLS TOTAL COUNT REF,,86357,302,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9386379,NK CELLS -TOTAL COUNT,,86357,302,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,9380750,CD3 (T CELLS) REF,,86359,302,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9386389,T CELL TOTAL COUNT REF,,86359,302,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9386422,"T CELLS, TOTAL COUNT",,86359,302,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9380751,CD4 (HELPER CELLS) REF,,86360,302,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9386391,T CELL ABSOLUTE COUNT REF,,86360,302,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9386421,T CELLS; ABS CD4&CD8 COUNT W/R,,86360,302,$670.00 ,$670.00 ,$187.60 ,$613.05 ,$469.00 ,$560.79 ,$613.05 ,$613.05 ,$613.05 ,$246.90 ,$402.00 ,$201.00 ,$603.00 ,$502.50 ,$536.00 ,$556.10
Hoopeston Regional Hlth Center,9380583,"THYROPEROXIDASE AB, S REF",,86376,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380955,"LIVER/KIDNEY MICROSOME ABS, S REF",,86376,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386375,MICROSOMAL ABS EACH REF,,86376,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386376,PEROXIDASE ANTIBODY REF,,86376,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386377,LUPUS PANEL-THYROID MICROSOMAL,,86376,302,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9380851,"POLIOVIRUS 1,2,3 ABS REF",,86382,302,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9380863,RABIES TITER-RESPONSE REF,,86382,302,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9380960,IFN-B NEUTRALIZATION TEST VIRAL REF,,86382,302,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9386382,VIRAL NUTRALIZATION TEST REF,,86382,302,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9386586,"CRYPTOCOCCUS AG, SERUM REF",,86403,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9386587,"CRYPTOCOCCUS AG, CSF REF",,86403,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9386431,"RHEUMATOID FACTOR, QUANT. REF",,86431,302,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9386362,RHEUMATOID FACTOR QUANTITATIVE,,86431,302,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9385426,TUBERCULSIS TEST;CELL IMMUN RF,,86480,302,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,9380832,ADENOVIRUS AB REF,,86603,302,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9386603,ADENOVIRUS ANTIBODY REF,,86603,302,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9386606,ASPERGILLUS AB REF,,86606,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9380427,"ASPERGILLUS FUMIGATUS, IGG AB REF",,86606,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9380466,"ASPERGILLUS FUMIGATUS, IGG AB REF",,86606,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9382996,BACTERIUM ANTIBODY REF,,86609,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386609,PNEUMOCOCCAL IGG ANTIBODY REF,,86609,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380549,"BARTONELLA AB PANEL, IGG, IGM REF",,86611,302,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9386594,BARTONELLA AB TITER REF,,86611,302,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9386611,BARTONELLA ANTIBODIES REF,,86611,302,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9386612,"BLASTOMYCES AB, SERUM REF",,86612,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386613,"BLASTOMYCES AB, CSF REF",,86612,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386615,BORDETELLA AB REF,,86615,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380439,"LYME DISEASE AB, IGG,IGM, WB, S REF",,86617,302,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9380741,"LYME DISEASE AB, WBLOT, CSF REF",,86617,302,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9386617,LYME AB CONFIRMTION W BLOT REF,,86617,302,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9386011,"LYME DISEASE SEROLOGY, CSF REF",,86618,302,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9380438,"LYME DISEASE SEROLOGY, S REF",,86618,302,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9386618,LYME AB SCREEN TOTAL REF,,86618,302,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9380375,"BRUCELLA AB SCREEN, IGG, IGM S REF",,86622,302,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9380376,"BRUCELLA TOTAL AB, AGGL, S REF",,86622,302,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9386622,BRUCELLA AB REF,,86622,302,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9386628,CANDIDA AB REF,,86628,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380978,CHLAMYDIA AB REF,,86631,302,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9386470,CHLAMYDIA ABS (IGG/A) REF,,86631,302,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9386631,LAB TEST REF,,86631,302,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9383131,CHLAMYDIA DETECTION,,86631,302,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9380979,"CHLAMYDIA AB, IGM REF",,86632,302,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9386480,CHLAMYDIA IGM AB REF,,86632,302,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9386632,LAB TEST REF,,86632,302,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9386450,COCCI ID-IGG REF,,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9386455,COCCI ID-IGM REF,,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9386635,"COCCIDIODES AB, SERUM REF",,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9386636,"COCCIDIODES AB, CSF REF",,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380718,"Q FEVER AB, IGG AND IGM, S REF",,86638,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380842,COX. BURNETII (Q FEVER) ABS REF,,86638,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380843,Q FEVER TITER(S) REF,,86638,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386638,COXIELLA BURNETII AB REF,,86638,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380836,"CYTOMEG IGG, ELISA (CSF) REF",,86644,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386306,CYTOMEGALOVIRUS (CMV) REF,,86644,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386644,CMV IGG ANTIBODY BY EIA REF,,86644,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386646,CMV IGG ANTIBODY,,86644,302,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9386988,CMV-NEGATIVE,,86644,302,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9380765,"CYTOMEGALOVIRUS AB, IGM, S REF",,86645,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380837,"CYTOMEG IGM, ELISA (CSF) REF",,86645,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9386645,CMV IGM ANTIBODY BY EIA REF,,86645,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9386647,CMV IGM ANTIBODY,,86645,302,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9386648,"DIPHTHERIA TOXOID IGG AB, S REF",,86648,302,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9380767,"CALIF ENCEP AB, IGG, IGM REF",,86651,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380823,"CALIFORNIA IGG, IGM REF",,86651,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386651,ENCEPHALITS AB CA(LA CROSSE)RF,,86651,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380768,"E. EQUINE ENCEPH AB, IGG, IGM REF",,86652,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380824,"EASTERN EQUINE IGG, IGM REF",,86652,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386652,ENCEPHALITIS AB EAST EQUINE RF,,86652,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380769,"ST. LOUIS ENCEPH AB, IGG, IGM REF",,86653,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380825,"ST. LOUIS IGG, IGM REF",,86653,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386653,ENCEPHALITIS AB ST LOUIS REF,,86653,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380770,"W. EQUINE ENCEPH AB, IGG, IGM REF",,86654,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380826,WESTERN EQUINE IGG REF,,86654,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386654,ENCEPHALITS AB WEST EQUINE REF,,86654,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386658,ENTEROVIRUS ANTIBODY REF,,86658,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380496,"COXSACKIE B(1-6) ANTIBODIES, S REF",,86658,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380497,"COXSACKIE A ANTIBODIES, S REF",,86658,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380498,"ECHOVIRUS ANTIBODIES, S REF",,86658,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380502,"POLIOVIRUS (TYPES 1-3) AB, S REF",,86658,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380835,ENTEROVIRUS ABS REF,,86658,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380840,"POLIOVIRUS (TYPES 1-3) AB, CSF REF",,86658,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9382320,COXSACKIE A AB PANEL REF,,86658,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9382325,COXSACKIE B(1-6)AB REF,,86658,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380942,"EBG IGG AB TO EARLY AG, S REF",,86663,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386663,EBV EARLY ANTIGEN ANTIBODY REF,,86663,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380756,"EBNA AB, S REF",,86664,302,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9386664,EBV NUCLEAR ANTIGEN REF,,86664,302,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9380755,"EBV VCA IGM, IGG AB, S REF",,86665,302,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9386665,EBV VIRAL CAPSID (IGG) REF,,86665,302,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9386666,EBV VIRAL CAPSID (IGM) REF,,86665,302,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9386595,EHRILICHIA ANTIBODY REF,,86666,302,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9380428,"M. FAENI-T. VULGARIS, IGG AB REF",,86671,302,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9386671,FUNGUS ANTIBODY REF,,86671,302,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9382927,HELICOBACTOR PYLORI AB REF,,86677,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9386677,HELICOBACTER PYLORI ANTIBODY,,86677,302,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9386682,HELMINTH ANTIBODY REF,,86682,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386684,"H INFLUENZAE B AB, IGG, S REF",,86684,302,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,9380455,"HTLV-I/-II AB SCREEN, S REF",,86687,302,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9380456,"HTLV-I/-II AB CONFIRMATION, S REF",,86689,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9380485,"HIV-1 AB CONFIRM W BLOT, S REF",,86689,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9380486,"HIV-1 AB CONFIRM BY IFA, S REF",,86689,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9380488,"HIV 2 AB, IMMUNOBLOT REF",,86689,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9386315,HTLV I/II W.BLOT REF,,86689,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9386530,LABORATORY TEST REF,,86689,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9386689,LABORATRY TEST FOR ANTIBDY REF,,86689,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9386692,"HEP D VIRUS IGM AB, EIA REF",,86692,302,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9380776,LABORATORY SERVICE REF,,86694,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380777,LABORATORY SERVICE REF,,86694,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386500,HSV IGM ANTIBODY TITER REF,,86694,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386694,HSV IGM ANTIBODY REF,,86694,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380757,LABORATORY SERVICE REF,,86695,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380830,"HSV 1 IGG INDEX, IGM IFA REF",,86695,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386695,HSV-1 IGG ANTIBODY REF,,86695,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380758,LABORATORY SERVICE REF,,86696,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9380831,"HSV 2 IGG INDEX, IGM IFA REF",,86696,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9386630,HSV-2 IGG ANTIBODY REF,,86696,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9386696,"HISTOPLASMA AB, CSF REF",,86698,302,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9386697,"HISTOPLASMA AB, SERUM REF",,86698,302,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9386698,"HISTOPLASMA AB SCREEN, SERUM REF",,86698,302,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9380487,"HIV-2 AB EVAL, S REF",,86702,302,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9386702,LABORATORY TEST,,86702,302,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9380140,LABRATORY TEST FOR ANTIBDY REF,,86703,302,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9386703,RAPID HIV-1 / HIV-2 AB SCREEN,,86703,302,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9380396,"HEPATITIS B CORE TOTAL AB, S REF",,86704,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9386704,HEPATITIS B CORE AB TOTAL REF,,86704,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380511,"HEPATITIS BE AB, S REF",,86707,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9386707,HEPATITIS BE ANTIBODY REF,,86707,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380729,"HEPATITIS A TOTAL AB, S REF",,86708,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9386708,HEPATITIS A ANTIBODY TOTAL REF,,86708,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9386709,HEPATITIS A IGM TITER REF,,86709,302,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9386292,HEPATITIS A IGM ANTIBODY,,86709,302,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9380833,"INFLUENZA A,B AB REF",,86710,302,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9386710,INFLUENZA VIRUS ANTIBODY REF,,86710,302,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9380382,"LEGIONELLA PNEUMOPHILA AB, S REF",,86713,302,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9386342,LEGIONELLA ANTIBODY REF,,86713,302,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9386717,LEISHMANIA REF,,86717,302,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9386720,"LEPTOSPIRA AB, S REF",,86720,302,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9386727,LCM VIRUS IGG & IGM ABS REF,,86727,302,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9380827,"LCM IGG, IGM REF",,86727,302,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9386257,MUMPS ANTIBODY REF,,86735,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380512,"MUMPS AB, IGM, S REF",,86735,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380829,"MUMPS AB IGG,IGM IFA REF",,86735,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386398,MUMPS ANTIBODY IGM REF,,86735,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386735,MUMPS ANTIBODY IGG,,86735,302,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9386738,MYCOPLSMA IGG ABS REF,,86738,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386413,MYCOPLASMA IGM AB BY EIA,,86738,302,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9380749,"PARVOVIRUS B19 AB, IGG, IGM, S REF",,86747,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9386747,PAROVIRUS B19 ANTIBODY REF,,86747,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9386753,"E. HISTOLYTICA AB, EIA REF",,86753,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9380841,RICKETTSIA ABS REF,,86757,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9380844,RMSF IGG TITER REF,,86757,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9380845,RMSF IGM TITER REF,,86757,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9380846,R. TYPHI IGG TITER REF,,86757,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9380847,R. TYPHI IGM TITER REF,,86757,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9386550,RICKETTTSIA ANTIBODYREF REF,,86757,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9386757,RICKETTSIA ANTIBODY REF,,86757,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9386765,MEASLES IGG ANTIBODY REF,,86765,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380513,"RUBEOLA (MEASLES) AB, IGM, S REF",,86765,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380828,"MEASLES (RUBEOLA) IGG, IGM IFA REF",,86765,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386495,MEASLES IGM AB REF,,86765,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386074,MEASELS IGG AB,,86765,302,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9386768,ANTIBODY; SALMONELLA REF,,86768,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380943,"TETANUS TOXOID IGG AB, S REF",,86774,302,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9386774,TETANUS ANTITOXOID AB REF,,86774,302,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9380572,"TOXOPLASMA AB, IGG, S REF",,86777,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386777,TOXOPL IGG AB BY EIA REF,,86777,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380571,"TOXOPLASMA AB, IGM, S REF",,86778,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386778,TOXOPL IGM AB BY EIA REF,,86778,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380860,LABORATORY SERVICE REF,,86780,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386780,LABORATORY SERVICE REF,,86780,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386781,LABORATORY TEST REF,,86780,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9386784,"TRICHINELLA AB, S REF",,86784,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9380834,VARICELLA-ZOSTER VIR AB REF,,86787,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386685,VZV ANTIBODY IGM BY EIA REF,,86787,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386787,"VARICELLA-ZOSTER AB, IGM, S REF",,86787,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386420,VARICELLA AB IGG ANTIBODY,,86787,302,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9380744,"WEST NILE VIRUS AB, IGM, S REF",,86788,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380772,"WEST NILE VIRUS AB, IGM REF",,86788,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380780,"WEST NILE VIRUS AB, IGM, CSF REF",,86788,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380839,WEST NILE VIRUS IGM REF,,86788,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9386788,ANTIBDY-WEST NILE VIRUS IGM RF,,86788,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9380743,"WEST NILE VIRUS AB, IGG, S REF",,86789,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380771,"WEST NILE VIRUS AB, IGG REF",,86789,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380779,"WEST NILE VIRUS AB, IGG, CSF REF",,86789,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9380838,WEST NILE VIRUS IGG REF,,86789,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386789,ANTIBODY -WEST NILE VIRUS REF,,86789,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9386565,ANTIBODY -VIRUS REF,,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380503,"DENGUE FEVER ABS (IGG,IGM) REF",,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380612,"SIN NOMBRE IGG CONFRM,IBL REF",,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380613,"SIN NOMBRE IGM CNFRM,ELISA REF",,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386188,ANTIBODY -VIRUS REF,,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9386790,"HANTAVIRUS ABS, ELISA",,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380752,"THYROGLOBULIN ANTIBODY, S REF",,86800,302,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9380982,"THYROGLOBULIN AB SCREEN, S REF",,86800,302,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9386800,THYROGLOBULIN ANTIBODY REF,,86800,302,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9386807,CYTOXIC ANTIBODY SCREENING REF,,86807,302,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9386808,CYTOXIC ANTIBODY SCREENING REF,,86808,302,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9386810,HLA TYPING A/B/C/-1 ANTIGN REF,,86812,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9386812,HLA-B27 ANTIGEN,,86812,302,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9380802,CELIAC ASSOC. HLA-DQ TYPING REF,,86816,302,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9380615,"ANTIBODY SCREEN, RBC, EACH REF",,86850,302,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,9386020,ANTIBODY SCREENING,,86850,302,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9386860,"ANTIBODY ELUTION (RBC), EACH REF",,86860,302,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9386026,ANTIBODY ELUTION,,86860,302,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9386870,"ANTIBODY ID, RBC, EACH PANEL REF",,86870,302,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9386021,ANTIBODY IDENTIFICATION PANEL,,86870,302,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9386880,"DIRECT COOMS (DAT), EACH REF",,86880,302,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9386250,DIRECT COMBS,,86880,302,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9386923,COMPATIBILITY TEST -EACH UNIT,,86923,302,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9386978,ALOADSORPTION REF,,86978,302,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9387337,E. HISTOLYTICA AG REF,,87337,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381453,"B CELLS, TOTAL COUNT REF",,86355,302,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9381452,"CD4 RET, FLOW CYTOMETRY REF",,86356,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9381455,HEPATITIS A TOTAL AB,,86708,302,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9381456,HEPATITIS B CORE TOTAL AB,,86704,302,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9381457,THYROGLOBULIN AB,,86800,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9381459,THYROPEROXIDASE AB,,86376,302,$98.00 ,$98.00 ,$27.44 ,$89.67 ,$68.60 ,$82.03 ,$89.67 ,$89.67 ,$89.67 ,$36.11 ,$58.80 ,$29.40 ,$88.20 ,$73.50 ,$78.40 ,$81.34
Hoopeston Regional Hlth Center,9381460,CARBOHYDRATE ANTIGEN 19-9,,86301,302,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380249,COLD AGGLUTININ SCREEN REF,,86156,302,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9380247,INFECTIOUS AGENT IMMUNOASSAY,,86318,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9380257,HSV 1/2 IGM TITER REF,,86696,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9381469,"DIPHTHERIA TOXOID IGG AB, S REF",,86317,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9381470,"TETANUS TOXOID IGG AB, S REF",,86317,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9381466,DS-DNA AB BY CRITHIDIA IFA REF,,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381473,LABORATORY TEST REF,,86780,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380630,CA125 (VISTA),,86304,302,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9381533,BACTERIUM ANTIBODY REF,,86609,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381540,"CHIKUNGUNYA IGG, IGM ABS REF",,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381551,BLASTOMYCES AB IMMUNODIFFUSION REF,,86612,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381559,"C-REACTIVE PROTEIN, HIGH SENSITIVITY REF",,86141,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381562,ALLRG SPC IGE ALPHA-GAL PANEL REF,,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9381564,UNFRAC HEPARIN DEP PLATELET AB REF,,86022,302,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9381568,"CYTOMEGALOVIURS AB, IGG (TRCHG) REF",,86644,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9381597,ALLERGEN SPECIFIC IGE REF,,86005,302,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381600,"TRYPANOSOMA CRUZI AB, IGG, S REF",,86753,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9381604,"TOXACARA ANTIBODY, SERUM, ELISA REF",,86682,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381605,NMO/AQP4-IGG FACS REF,,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381606,NMO/AQP4-IGG FACS TITER REF,,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381615,"STREPTOZYME SCREEN 2/REFLEX, TITER REF",,86403,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381616,STREPTOZYME TITER REF,,86406,302,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9381653,"EMA TITER, S (IGA) REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381661,"AVIAN PANEL, REF",,86331,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380648,"ANTIBODY INFLUENZA VIRUS, YERSINIA REF",,86793,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9380680,TB QUANTIFERON,,86480,302,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9381668,"CD 57 NK VALUES, REF",,86356,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9381669,"ECHINOCOCCUS ANTIBODY IGG, SERUM, REF",,86682,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381673,"ANAPLASMA PHAGOCYTOPHILUM AB, REF",,86666,302,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381674,"BABESIA MICROTI AB, REF",,86753,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9381682,"DEMENTIA-AUTOIMMUNE EVALUATION, CSF, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381685,HETEROPHILE ANTIBODY SCREEN REF,,86038,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381686,HETEROPHILE ANTIBODY TITER REF,,86309,302,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9381687,FILARIA IGG4 ANTIBODY REF,,86682,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381688,"STRONGYLOIDES AB, S, REF",,86682,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381692,"LYMPHOCYTE SUBSET 4, PCT AND RATIO, BAL, REF",,86356,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9381693,"LYME DISEASE ANTIBODY, IGM",,86618,302,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9381695,"LYME DISEASE ANTIBODY, IGG",,86618,302,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9381700,"NEUROIMMUNOLOGY LAB BIOCHEM ZNT8 AB, REF",,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9381720,"N. MENINGITIDIS TETRAVALENT ANTIBODIES, REF",,86741,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9381726,"HEPATITIS D TOTAL AB, S",,86692,302,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9381620,"IMMUNOFIXATION, U, REF",,86335,302,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9381727,LABORATORY TEST,,86780,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9381705,"(-2) PROPSA, S",,86316,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9381739,"LYME CNS INFECTION IGG SCREEN, CSF, REF",,86618,302,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9381742,"LYME DISEASE ANTIBODY, REF",,86618,302,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9381772,"PARANEOPLASTIC AUTOANTIBODY EVAL, CSF, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381031,T/B CELL QUANT NK CELLS REF,,86357,302,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9381033,"COMPLEMENT C1Q, S REF",,86160,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381036,"IMMUNODIFFUSEION OUCHTERLONY, REF",,86331,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381044,CD20 TOTAL COUNT REF,,86356,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9381094,DIRECT BACTERIAL AG-PARTICLE AGGLUT.EACH,,86403,302,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9381101,"COCCIDIOIDES AB SCREEN, SERUM REF",,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381100,"COCCIDIOIDES AB SCREEN, SCF REF",,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381120,LABORATORY SERVICES,,86702,302,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9381121,"FL NONINF AGENT AB; SCRN, EA REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381122,"FL NONINF AGENT AB; TITER, EA REF",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381123,"SRA UNFRACTIONED HEPARIN, REF",,86022,302,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9381792,"MYOCARDIAL ABS, S, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381800,"NMDA RECEPTOR ANTIBODY TEST, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381805,"SPOTTED FEVER AB, REF",,86757,302,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9381804,"MURINE TYPHUS AB, REF",,86757,302,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9381127,CHIKUNGUNYA IGG-IGM SCREEN REF,,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381128,CHIKUNGUNYA IGG TITRATION REF,,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381129,CHIKUNGUNYA IGM TITRATION REF,,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381138,N.K. CYTOXICITY REF,,86805,302,$760.00 ,$760.00 ,$212.80 ,$695.40 ,$532.00 ,$636.12 ,$695.40 ,$695.40 ,$695.40 ,$280.06 ,$456.00 ,$228.00 ,$684.00 ,$570.00 ,$608.00 ,$630.80
Hoopeston Regional Hlth Center,9381140,"AB TO EXTRACTABLE NUCLEAR AG EVAL, S REF",,86325,302,$93.00 ,$93.00 ,$26.04 ,$85.10 ,$65.10 ,$77.84 ,$85.10 ,$85.10 ,$85.10 ,$34.27 ,$55.80 ,$27.90 ,$83.70 ,$69.75 ,$74.40 ,$77.19
Hoopeston Regional Hlth Center,9381150,PHADIATOP (RESPIRATORY ALLERGY) REF,,86005,302,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381813,"CYSTICERCOSIS ANTIBODY, IGG, REF",,86682,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381816,"TAU PROTEIN, REF",,86317,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9381817,"GEL DIFFUSION, QUAL, EACH, REF",,86331,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381821,"FRANCISELLA TULARENSIS AB, REF",,86000,302,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9381818,"(CSF) TAU, REF CASE WESTERN",,86317,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9381824,"MOG FACS, S, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381838,"ZINC TRANSPORTER 8 (ZNT8) ANTIBODY, SERUM, REF",,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9381844,"SOLUBLE MESOTHELIN, REF",,86316,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9381833,HIV-2 ANTIBODY,,86702,302,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9381849,"CHLAMYDIA IGM ANTIBODY, REF",,86632,302,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9381854,"AGGLUTININS, FEBRILE, EACH ANTIGEN",,86000,302,$28.00 ,$28.00 ,$7.84 ,$25.62 ,$19.60 ,$23.44 ,$25.62 ,$25.62 ,$25.62 ,$10.32 ,$16.80 ,$8.40 ,$25.20 ,$21.00 ,$22.40 ,$23.24
Hoopeston Regional Hlth Center,9381856,"AC/HS TOXOPLASMOSIS TESTING, REF",,86406,302,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9381862,"SRP IFA SCREEN, S, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381870,"NUCLEAR ANTIGEN ANTIBODY, REF",,86235,302,$80.00 ,$80.00 ,$22.40 ,$73.20 ,$56.00 ,$66.96 ,$73.20 ,$73.20 ,$73.20 ,$29.48 ,$48.00 ,$24.00 ,$72.00 ,$60.00 ,$64.00 ,$66.40
Hoopeston Regional Hlth Center,9381880,"ANTI-NEURONAL NUCLEAR AB, TYPE 1, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381908,"OVARIAN ANTIBODY SCREEN, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381909,"GALACTOSE-ALPHA-1, 3-GALACTOSE (ALPHA-GAL), IGE, REF",,86008,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9381924,"BIRD FANCIER'S PRECIPITIN PANEL 1, REF",,86331,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381926,"HTLV-1/-11 AB, SCREEN, S, REF",,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381939,TB QUANTIFERON-PLUS,,86481,302,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,9381940,"SACCHAROMYCES CER AB, IGA, REF",,86671,302,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9381951,"HEPATITIS E VIRUS IGM AB SCREEN, REF",,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381954,"FLUORESCENT AB SCREEN, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381969,"F. TULARENSIS AB, S",,86668,302,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9381979,"ISLET CELL AB SCREEN/TITER, REF",,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9381980,"IGE HAZELNUT COMPONENT PROFILE, REF",,86008,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9381982,"MVISTA HISTOPLASMA IGG, IGM AB BY EIA, REF",,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9381987,"ALLERGY PROFILE, REF",,86008,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9381996,"HUMAN HERPES VIRUS, REF",,86790,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9381999,"LYMPHOCYTE PROLIFERATION MITOGENS, REF",,86353,302,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9382185,"MONONUCLEAR CELL ANTIGEN, REF",,86356,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9382192,GLOMERULAR BASEMENT MEMBRANE AB IGG REF,,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382196,"LRP4 AUTOANTIBODY TEST, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382197,"FIBRILLARIN (U3 RNP) AB, IGG, REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382298,"LYMPHOCYTE SUBSET PANEL 4 - CD4/CD8 - BRONCH, REF",,86356,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9382303,"CELIAC DISEASE PANEL, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382360,"Hc Lymphocyte Subset Panel 4, Ref",,86360,302,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9382363,"SERUM IMMUNOFIXATION, REF",,86334,302,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382376,"HEP B CORE AB, TOTAL, REF",,86704,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382433,"SRP AUTOANTIBODIES, REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382351,ANTISTREPTOLYSIN O,,86060,302,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9382439,"ANTI-DSDNA, REFLUS, TITER, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382440,UA-DIP W/MICRO REF,,86225,302,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9382444,ANA TITER & PATTERN REF,,86039,302,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9382451,"STREPTOCOCCUS PNEUMONIAE S, REF",,86317,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9382454,"SACCHAROMYCES CEREVISIAE AB, REF",,86021,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9382459,"FLOW CYTOMETRY NEUTROPHILS AB, REF",,86021,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9382470,INHIBIN A,,86336,302,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9382476,"NSE NEURON SPECIFIC ENOLASE, REF",,86316,302,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9382496,"BASOFUNCTION HRT, REF",,86343,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9382486,"PHOSPHATIDYLSERINE AB, REF",,86148,302,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9382488,"MSA AB PANEL, REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382526,"THSD7, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382528,"LYMPHOCYTE SUBSET PANEL 5, REF",,86361,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9382559,"GABA-BR AB, IGG BY IFA W/REFLUX TO TITER, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382346,"CENTROMERE AB, REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9382548,"LYMPHOCYTE SUBSET PANEL 4, B",,86360,302,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9382592,"ADRENAL AB SCREEN WITH/REFLUX TO TITER, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382609,"ASPERGILLUS IGG PRECIPITINS PANEL, REF",,86331,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382604,"CPT-CARDIOLIPIN AB, EACH IG CLASS",,86147,302,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9382569,"LIVER KIDNEY MICROSOMAL (LKM-1) ABS (IGG), S REF",,86376,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9382574,ASPERGILLUS FUMIGATUS,,86606,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9382572,"BACTERIUM, ANTIBODY",,86609,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9382576,ALLERGEN SPECIFIC IGG,,86001,302,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9382568,"ALLERGEN SPECIFIC IGE, EACH, REF",,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9382614,"ANCA SCREEN W/REFLEX TO ANCA TITER, REF",,86021,302,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9382683,"PHOSPHOLIPASE A2 RECEPTOR IFA, S, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382716,"HP DIABETES TYPE 1 EVAL, ANTIBODY REF",,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9382717,"HP DIABETES TYPE 1 EVAL, INSULIN AB REF",,86337,302,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9382764,"MITOCHONDRIAL AB SCREEN, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382578,"AB TO TP ANTIGEN(IGM), ID",,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9382579,"COCCIDIOIDES AB, CF, SERUM",,86635,302,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9382772,"TOXOCARA AB, IGG, S, REF",,86682,302,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9382794,"ACHR MODULATING FLOW CYTO, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382822,"PARANEOPLAS AUTOAB EVAL, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382823,"ANTISTREP-O TITER, S , REF",,86060,302,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9382824,HEPATITIS A IGG AB,,86708,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9382830,"DYSAUTONOMIA, INTER, S, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382825,CRYOCRIT IMMUNOFIXATION,,86334,302,$89.00 ,$89.00 ,$24.92 ,$81.44 ,$62.30 ,$74.49 ,$81.44 ,$81.44 ,$81.44 ,$32.80 ,$53.40 ,$26.70 ,$80.10 ,$66.75 ,$71.20 ,$73.87
Hoopeston Regional Hlth Center,9382826,CRYOCRIT IMMUNODIFFUSION,,86329,302,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9382810,"AQUAPORIN-4 (AQP4)(NMO-IGG) AB W/RFX TO TITER, B [REF]",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382811,"AQUAPORIN-4 (AQP4(NMO-IGG) AB TITER, B [REF]",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382808,"MYELIN OLIGODENDRYTE GLYCOPROTEIN (MOG) AB W/RFX TO TITER, B [REF]",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382809,"MOG AB TITER, B [REF]",,86256,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382976,"CU INDEX, REF",,86343,302,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9383066,"MI 2 AUTOANTIBODIES, REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9383071,FTA-ABS,,86780,302,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9382982,"CMV IGG AB, REF",,86644,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9382983,"TOXOPLASMA AG, IGM, REF",,86778,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9382984,"TOXOPLASMA AG, IGG, REF",,86777,302,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9383106,"ALLERGY-SHELLFISH PANEL, B [REF]",,86003,302,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9383114,"MYOMARKER 3 PROFILE, REF",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9383136,"AMPA RECEPTOR AB IGG SCREE, CSF, REF",,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9383137,"NEUROMYELITIS OPTICA/AQP4-IGG, CSF, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9383081,"CMV IGM AB, REF",,86645,302,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,9383167,"STRIATED MUSCLE AB SCREEN, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9383169,"KELCH-LIKE PROTEIN 11 AB, CBA, S, REF",,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9383158,"RITUXAN SENSITIVITY (CD20), B [REF]",,86356,302,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9383173,"EXTRACTABLE NUCLEAR ANTIGEN, EACH",,86235,302,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9381230,"ISLET ANTIGETN 2 (IA-2) AB, S REF",,86341,302,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9381247,HU ANTIBODY SCREEN WITH REFLEX REF,,86255,302,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9385004,AUTOMATED DIFFERENTIAL WBC,,85004,305,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9385009,MAN DIFF WBC COUNT BUFFY COAT,,85009,305,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9380141,MICROHEMATOCRIT -SPUN,,85013,305,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9385013,SPUN MICROHEMATOCRIT,,85013,305,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9385005,HEMATOCRIT REF,,85014,305,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9385055,HEMATOCRIT,,85014,305,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9385031,HEMOGLOBIN REF,,85018,305,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9385050,HEMOGLOBIN,,85018,305,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9385016,CBC W/AUTOMATED DIFFERENTIAL,,85025,305,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9385017,CBC W/O DIFFERENTIAL,,85027,305,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9385032,MANUAL BLOOD CELL COUNT REF,,85032,305,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9385095,RED BLOOD CELL COUNT REF,,85041,305,$12.00 ,$12.00 ,$3.36 ,$10.98 ,$8.40 ,$10.04 ,$10.98 ,$10.98 ,$10.98 ,$4.42 ,$7.20 ,$3.60 ,$10.80 ,$9.00 ,$9.60 ,$9.96
Hoopeston Regional Hlth Center,9385020,RED BLOOD CELL COUNT ONLY,,85041,305,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9385030,WHITE CELL COUNT,,85048,305,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9385595,PLATELET PROFILE,,85049,305,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9385130,CHROMOGENIC SUBSTRTE ASSAY REF,,85130,305,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380908,CLOTTING FACTOR II REF,,85210,305,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9385210,CLOTTING FACTOR II,,85210,305,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,9380909,CLOTTING FACTOR V REF,,85220,305,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9385220,CLOTTING FACTOR V,,85220,305,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,9380910,CLOTTING FACTOR VII REF,,85230,305,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9385230,CLOTTING FACTOR VII,,85230,305,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,9385290,CLOTTNG FACTR VIII ACTIVTY REF,,85240,305,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9385240,CLOTTING FACTOR VIII,,85240,305,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9380447,"RISTOCETIN COFACTOR, P REF",,85245,305,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9385172,"VWF, RISTOCETIN COFACTOR REF",,85245,305,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9385245,"VWF, RISTOCETIN COFACTOR REF",,85245,305,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9380924,"VON WILLEBRAND FACTOR AG, P REF",,85246,305,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9385171,VW FACTOR ANTIGEN REF,,85246,305,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9385246,VW FACTOR ANTIGEN REF,,85246,305,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9385165,"VW FACTOR, MULTIMETRIC REF",,85247,305,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9385247,"VON WILLEBRAND FACTOR MULTIMER, P REF",,85247,305,$92.00 ,$92.00 ,$25.76 ,$84.18 ,$64.40 ,$77.00 ,$84.18 ,$84.18 ,$84.18 ,$33.90 ,$55.20 ,$27.60 ,$82.80 ,$69.00 ,$73.60 ,$76.36
Hoopeston Regional Hlth Center,9385242,CLOTTING FACTOR IX REF,,85250,305,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9385250,CLOTTING FACTOR IX,,85250,305,$750.00 ,$750.00 ,$210.00 ,$686.25 ,$525.00 ,$627.75 ,$686.25 ,$686.25 ,$686.25 ,$276.38 ,$450.00 ,$225.00 ,$675.00 ,$562.50 ,$600.00 ,$622.50
Hoopeston Regional Hlth Center,9385261,CLOTTING FACTOR X REF,,85260,305,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9385260,CLOTTING FACTOR X,,85260,305,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9385270,CLOTTING FACTOR XI ACTIVTY REF,,85270,305,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9385280,CLOTTING FACTOR XII ACTIV REF,,85280,305,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,9385109,"FACTOR XIII, FUNCTIONAL REF",,85290,305,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9385291,FACTR XIII SOLUBILTY SCREEN RF,,85291,305,$36.00 ,$36.00 ,$10.08 ,$32.94 ,$25.20 ,$30.13 ,$32.94 ,$32.94 ,$32.94 ,$13.27 ,$21.60 ,$10.80 ,$32.40 ,$27.00 ,$28.80 ,$29.88
Hoopeston Regional Hlth Center,9380986,PREKALLIKREIN (FLETCHER FACTOR) REF,,85292,305,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9385293,HMW KININOGEN ASSAY REF,,85293,305,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9385300,ANTITHROMBIN ACTIVITY REF,,85300,305,$47.00 ,$47.00 ,$13.16 ,$43.01 ,$32.90 ,$39.34 ,$43.01 ,$43.01 ,$43.01 ,$17.32 ,$28.20 ,$14.10 ,$42.30 ,$35.25 ,$37.60 ,$39.01
Hoopeston Regional Hlth Center,9385307,ANTITHROMBINE III ACTIVITY,,85300,305,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9385301,ANTITHROMBIN ANTIGEN SEW REF,,85301,305,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9385303,PROTEIN C ACTIVITY REF,,85303,305,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9385310,"PROTEIN C, ACTIVITY",,85303,305,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9385335,FACTOR INHIBITOR TEST REF,,85335,305,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9385392,"D-DIMER, ULTRASENSITIVE",,85379,305,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9385375,FIBRINOGEN,,85384,305,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9380243,FIBRINOLYSIS OR COAG SCRN INTERP& RPT REF,,85390,305,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9380217,COAG FUNCTIONAL ACTIVITY EA REF,,85397,305,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9385410,ALPHA-2 ANTIPLASMIN ACTVIT REF,,85410,305,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9385415,PLASMINOGEN ACTIVATOR REF,,85415,305,$69.00 ,$69.00 ,$19.32 ,$63.14 ,$48.30 ,$57.75 ,$63.14 ,$63.14 ,$63.14 ,$25.43 ,$41.40 ,$20.70 ,$62.10 ,$51.75 ,$55.20 ,$57.27
Hoopeston Regional Hlth Center,9385420,PLASMINOGEN ACTIVITY REF,,85420,305,$26.00 ,$26.00 ,$7.28 ,$23.79 ,$18.20 ,$21.76 ,$23.79 ,$23.79 ,$23.79 ,$9.58 ,$15.60 ,$7.80 ,$23.40 ,$19.50 ,$20.80 ,$21.58
Hoopeston Regional Hlth Center,9385421,PLASMINOGEN ANTIGEN REF,,85421,305,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9380967,"HEPARIN ANTI-XA ASSAY, P REF",,85520,305,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9385520,HEPARIN ASSAY REF,,85520,305,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380974,LEUCKOCYTE ALK PHOS (LAP) W/ COUNT REF,,85540,305,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,9385540,LEUKOCYTE ALKALINE PHOSPHATASE,,85540,305,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9385538,LYSOZYME/MURAMIDASE REF,,85549,305,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9385549,"LYSOZYME (MURAMIDASE), PL REF",,85549,305,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,9385557,"OSMOTIC FRAG,RBC,INCUBATED REF",,85557,305,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9385600,PLATELET AGGREGATION,,85576,305,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,9385597,PLATELET NEUTRALIZATION REF,,85597,305,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9380570,PHOSPHOLIPID NEUT; HEXAGONAL REF,,85598,305,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9380985,PROTHROMBIN TIME REF,,85610,305,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9385610,PROTHROMBIN TIME,,85610,305,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9385001,LUPUS ANTICOAGULANT,,85613,305,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9385613,RVVT DILUTED REF,,85613,305,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9385660,"HEMOGLOBIN S, SCRN, B REF",,85660,305,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9385661,SICKLE CELL SCREEN,,85660,305,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9385012,URINE EOS,,85999,305,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9385350,EOSINOPHIL COUNT,,85999,305,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9381448,"VON WILLEBRAND FACTOR ACTIVITY, P REF",,85397,305,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9381447,"COAG FACTOR VIII ACTIVITY ASSAY, P REF",,85240,305,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9381450,"COAG FACTOR VIII ASSAY INHIB SCRN, P REF",,85335,305,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9381449,BETHESDA UNITS REF,,85335,305,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9381451,SPECIAL COAG INTERPRETATION REF,,85390,305,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,8085610,PT,,85610,305,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9381490,"OSMOTIC FRAGILITY, ERYTHROCYTE REF",,85555,305,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9381541,FACTOR VIII ANTIGEN REF,,85244,305,$82.00 ,$82.00 ,$22.96 ,$75.03 ,$57.40 ,$68.63 ,$75.03 ,$75.03 ,$75.03 ,$30.22 ,$49.20 ,$24.60 ,$73.80 ,$61.50 ,$65.60 ,$68.06
Hoopeston Regional Hlth Center,9381546,PROTHROMBIN TIME-INCUBATED,,85610,305,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381586,"FIBRINOGEN, P REF",,85384,305,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,8285014,HEMATOCRIT,,85014,305,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,8285347,"COAGULATION TIME, ACTIVATED",,85347,305,$59.00 ,$59.00 ,$16.52 ,$53.99 ,$41.30 ,$49.38 ,$53.99 ,$53.99 ,$53.99 ,$21.74 ,$35.40 ,$17.70 ,$53.10 ,$44.25 ,$47.20 ,$48.97
Hoopeston Regional Hlth Center,9380992,PLATELET FUNCTION P2Y12,,85576,305,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,9381011,TEG COAG TIME; ACTIVATED,,85347,305,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381012,FIBRINOGEN; ACTIVITY,,85384,305,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,9381013,TEG FIBRINOLYSIS OR COAG SCRN INTERP & RPT,,85390,305,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9381014,"TEG PLATELET AGGREGATION, EA",,85576,305,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,8285379,D-DIMER (POC),,85379,305,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9381039,"ALPHA-2 PLASMIN INHIBITOR, P REF",,85410,305,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,8085014,HCT,,85014,305,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,8085347,ISTAT ACT,,85347,305,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381188,D-DIMER REF,,85379,305,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381194,HC ADAMTS13 ACTIVITY REF,,85397,305,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9381195,ADAMTS14 INHIBITOR REF,,85335,305,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9380338,POC PROTHROMBIN TIME,,85610,305,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9381839,"STACLOT APTT, REF",,85598,305,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9381841,"OSMOTIC FRAGILITY, REF",,85557,305,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9381946,"RETICULOCYTE COUNT, AUTOMATED",,85046,305,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9382195,"HEPARIN, LMWH (ANTI XA)",,85130,305,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382422,"ANTI-XA, PLASMA",,85520,305,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9382814,"ADAMTS13 ACTIVITY W/RFX TO INHIBITOR, B [REF]",,85397,305,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9382815,"ADAMTS13 INHIBITOR, B [REF]",,85335,305,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9382968,"FACTOR VIII ACTIVITY, CLOTTING, B [REF]",,85240,305,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,9383147,"HEPARIN, ANTI-XA ASSAY",,85520,305,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,85014,HEMATOCRIT,,85014,305,$38.00 ,$38.00 ,$10.64 ,$34.77 ,$26.60 ,$31.81 ,$34.77 ,$34.77 ,$34.77 ,$14.00 ,$22.80 ,$11.40 ,$34.20 ,$28.50 ,$30.40 ,$31.54
Hoopeston Regional Hlth Center,85018,HEMOGLOBIN,,85018,305,$33.00 ,$33.00 ,$9.24 ,$30.20 ,$23.10 ,$27.62 ,$30.20 ,$30.20 ,$30.20 ,$12.16 ,$19.80 ,$9.90 ,$29.70 ,$24.75 ,$26.40 ,$27.39
Hoopeston Regional Hlth Center,9381423,LEGIONELLA PCR REF,,87801,306,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9380535,"CYCLOSPORA, CONCENTRATION REF",,87015,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9382931,CONCENTRATION-INFECT AGNTS REF,,87015,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9387015,"CONCENTRATION, CYCLOSPORA REF",,87015,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9387017,"CONCENTRATION, INFECT AGENTS",,87015,306,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9387088,"CULTURE, BACT;OTHR SRC REF",,87070,306,$34.00 ,$34.00 ,$9.52 ,$31.11 ,$23.80 ,$28.46 ,$31.11 ,$31.11 ,$31.11 ,$12.53 ,$20.40 ,$10.20 ,$30.60 ,$25.50 ,$27.20 ,$28.22
Hoopeston Regional Hlth Center,9387060,UPPER RESPIRATORY CULTURE,,87070,306,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9387070,BACT CULT ISOL/PRESMPTV ID OTH,,87070,306,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9387071,ENVIRONMENTAL CULT/BACT,,87070,306,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9387066,BACT CULT QUANT AEROBIC W/ISO,,87071,306,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9387067,BACT CULT QUANT ANA W/ISO,,87073,306,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9380239,ANAEROBIC CULTURE,,87073,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9384800,BACTERIAL CULTURE ID REF,,87076,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9387077,BACT CULT DEF ID ANAEROBIC,,87076,306,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9384695,BACTERIAL CULTURE ID REF,,87077,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9387068,BACT CULT DEF ID AEROBIC,,87077,306,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9387084,BACT CULTURE SCREENNG ONLY REF,,87081,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9387081,BACT CULTURE SCREENING ONLY,,87081,306,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9387085,BACT CULTURE SCREENING ONLY,,87081,306,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9387086,UREA TEST FOR H. PYLORI,,87077,306,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9387087,VRE SCREEN,,87081,306,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9380242,UPPER RESPIRATORY CULTURE,,87081,306,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9385369,FUNGL IDENTIFICATION-YEAST REF,,87106,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9387003,"FUNGAL IDENTIFICATION, YEAST",,87106,306,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9396935,FUNGAL SCRAPING & INTERP,,87106,306,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9385364,FUNGAL IDENTIFICATION-MOLD REF,,87107,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9387107,"FUNGAL IDENTIFICATION, MOLD",,87107,306,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9387109,MYCOPLASMA CULTURE REF,,87109,306,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,9387139,CULTURE TYPING; IMMUNOFL REF,,87140,306,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9387149,CULTURE IMMUNOFL TYPING REF,,87140,306,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9384810,CULTURE TYPING REF,,87143,306,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9387143,AFB CHROMATOGRAPHY REF,,87143,306,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,9385101,CULTURE TYPING REF,,87149,306,$80.00 ,$80.00 ,$22.40 ,$73.20 ,$56.00 ,$66.96 ,$73.20 ,$73.20 ,$73.20 ,$29.48 ,$48.00 ,$24.00 ,$72.00 ,$60.00 ,$64.00 ,$66.40
Hoopeston Regional Hlth Center,9387178,"AFB ID, DNA, PROBE TECH",,87149,306,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9380149,AMP PROB TECH EA ORGANISM,,87150,306,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9387152,CULTURE TYPE ID BY PFGE,,87152,306,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9387350,DARK FIELD EXAM,,87164,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387168,MACROSCOPIC EXAM -ARTHROPOD,,87168,306,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9387172,PIMWORM EXAM,,87172,306,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9387177,OVA AND PARASITE EXAM,,87177,306,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9387181,SENSITIVITY STUDIES REF,,87181,306,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9384613,SENSITIVITY STUDIES REF,,87184,306,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9385368,SUSCEPTBLTY STUDY PER PLTE REF,,87184,306,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9387006,"SUSCEPTIBILTY,DISK DIFFUSN REF",,87184,306,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9387001,"SUSCEPTIBILITY, DISK DIFFUSION",,87184,306,$980.00 ,$980.00 ,$274.40 ,$896.70 ,$686.00 ,$820.26 ,$896.70 ,$896.70 ,$896.70 ,$361.13 ,$588.00 ,$294.00 ,$882.00 ,$735.00 ,$784.00 ,$813.40
Hoopeston Regional Hlth Center,9387179,BETA LACTAMASE DETECTION,,87185,306,$84.00 ,$84.00 ,$23.52 ,$76.86 ,$58.80 ,$70.31 ,$76.86 ,$76.86 ,$76.86 ,$30.95 ,$50.40 ,$25.20 ,$75.60 ,$63.00 ,$67.20 ,$69.72
Hoopeston Regional Hlth Center,9384614,SENSITIVITY STUDIES REF,,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9384615,SENSITIVITY STUDIES REF,,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9385365,SENSITIVITY STUDIES REF,,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9387007,SENSITIVITY STUDIES REF,,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9387186,"SUSCEP;MIC,EA PLATE REF",,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9387188,SENSITIVITY STUDIES REF,,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9387120,SENSITIVITY STUDIES,,87186,306,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9385367,SENSITIVITY STUDIES REF,,87187,306,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9387183,MIN BACTERIACIDAL LEVEL,,87187,306,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9386540,SUSCEPTIBILTY STUDY EA AGNT RF,,87188,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9380536,CYCLOSPORA STAIN REF,,87207,306,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9380977,CYCLOSPORA STAIN REF,,87207,306,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9382932,MICRO SPECIAL STAIN -REF,,87207,306,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9385550,"SMEAR, MALRIA/BLOOD PARASITE",,87207,306,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9387211,MICRO SPECIAL STAIN,,87207,306,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9387209,SMEAR -COMPLEX STAIN,,87209,306,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9387220,TISSUE EXAM BY KOH SLIDE REF,,87220,306,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9387010,"TISSUE EXAM, KOH MOUNT",,87220,306,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9387230,TISSUE CULTRE TOXN/ANTITOXN RF,,87230,306,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9380490,"VIRAL CULTURE, NON-RESPIR REF",,87252,306,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9387251,"TISSUE CULTURE, VIRUS ISOL REF",,87252,306,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9387252,CMV CONVENTIONAL CULTURE REF,,87252,306,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9380961,IFN-B TISSUE CULTURE REF,,87253,306,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9387198,"VIRS ISOL,DEF IDBYNEUTRALZ REF",,87253,306,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9386076,"VIRUS ISOLTN,SHELL VIALMTHD RF",,87254,306,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9387155,CMV RAPID CULTURE REF,,87254,306,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9387255,HSV CULT ID W/IMMUNOSTAIN,,87254,306,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9388144,GENET VIRUS ISO HSV REF,,87255,306,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9387271,CYTOMEGALOVIRUS DFA REF,,87271,306,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9387272,CRYPTOSPORIDIUM ANTIGEN REF,,87272,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9387279,PARAINFLUENZA ANTIGEN TEST REF,,87279,306,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,9387281,PNEUMOCYSTIS CARINII IMMFL TCH,,87281,306,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9380946,ASPERGILLUS (GALACTOMANNAN) AG REF,,87305,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9384434,ASPERGILLUS ANTIGEN REF,,87305,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9387324,CLOSTRIDIUM DIFFICILE TOXIN A,,87324,306,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9380133,CRYPTOCOCCUS AG SCREEN CSF REF,,87327,306,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9387327,CRYPTOCOCCUS AG SCRN SERUM REF,,87327,306,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9387328,CRYPTOSPORIDIUM ANTIGEN,,87328,306,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9387329,GIARDIA ANTIGEN,,87329,306,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9387338,"H.PYLORI ANTIGEN, STOOL",,87338,306,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9380437,"HBS ANTIGEN CONFIRMATION, S REF",,87341,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9387341,HBSAG CONFRM BY NEUTRALIZTN RF,,87341,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9380504,"HEPATITIS BE AG, S REF",,87350,306,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9386683,HEPATITIS BE ANTIGEN REF,,87350,306,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9380822,"MVISTA HISTOPLASMA AG, S REF",,87385,306,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9387385,HISTOPLASMA ANTIGEN REF,,87385,306,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9387390,LABORATORY TEST REF,,87390,306,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9387427,INFECTIOUS AGENT DETECTION REF,,87427,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9380139,INFECTIOUS AGENT DETECTION,,87427,306,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9380240,"BETA STREP, RAPID",,87430,306,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9380848,MVISTA BLASTOMYCES QUANT AG REF,,87449,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9384447,BLASTOMYCES ANTIGEN REF,,87449,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9387151,INFECTIOUS AGENT AG EIA REF,,87449,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9387447,"BLASTOMYCES AG, FLUID",,87449,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9387449,INFECTIOUS AGENT ANTIGEN,,87899,306,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9387451,GIARDIA/CRYPTOSPORIDIUM SCREEN,,87451,306,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9387471,"BARTONELLA DNA, PCR REF",,87471,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387476,BORRELIA BURGDORGRI DETCTN REF,,87476,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387486,INFCT AGNT DETECTN DIR PRBE RF,,87486,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387493,C DIFF TOXIN BY PCR,,87493,306,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,9387496,INFECTIOUS AGENT DETECTION REF,,87496,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387497,"CMV DNA QUANT, PCR REF",,87497,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9380135,CYTOMEG DNA - QUANT,,87497,306,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9387498,ENTEROVIRUS-AMPLIFID PROBE REF,,87498,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380143,ENTEROVIRUS BY PCR,,87498,306,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,9387500,"INFLU VIRUS, MULT TYPES, FIRST 2",,87502,306,$385.00 ,$385.00 ,$107.80 ,$352.28 ,$269.50 ,$322.25 ,$352.28 ,$352.28 ,$352.28 ,$141.87 ,$231.00 ,$115.50 ,$346.50 ,$288.75 ,$308.00 ,$319.55
Hoopeston Regional Hlth Center,9387502,HUMAN INFLUENZA A,,87502,306,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9387503,FLU A SUBTYPES,,87503,306,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9380709,"HEP B VIRUS DNA QNT BY BDNA, S REF",,87517,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9380778,"HBV DNA DETECT/QNT, PCR, S REF",,87517,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9387517,HEPATITIS B VIRUS-DNA QUANT RF,,87517,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9380759,"HEPATITIS C AMPLIF, RT-PCR REF",,87521,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387521,"HCV RNA BY PCR, QUAL REF",,87521,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387522,HCV RNA BY PCR QUANT REF,,87522,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9380618,RNA QUANT BY PCR,,87522,306,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9387529,HSV AMPLIFIED PROBE REF,,87529,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9385560,INFECTIOUS AGENT DETECTION,,87529,306,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9387530,HSV DNA QUANTIFICATION REF,,87530,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9387532,HERPES VIRUS-6 PROBE TECH REF,,87532,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387535,LABORATORY TEST REF,,87535,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387199,LABORATORY TEST REF,,87536,306,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9387536,LABORATORY TEST REF,,87536,306,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9380617,HIV-1 RNA,,87536,306,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,9389401,"HIV-1 RNA QUANT, BY PCR",,87536,306,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9387556,M.TUBERCULOSIS AMPL PROBE REF,,87556,306,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9387561,"M. AVIUM-INTRACLAR,AMP PRB REF",,87561,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387581,MYCOPLSMA PNEUMNIA AMP PRBE RF,,87581,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387640,STAPH AUREUS AMP PROBE,,87640,306,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9380305,MRSA AMPI PROBE,,87641,306,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9387641,STAPH AUREUS-METHICILLN RESIST,,87641,306,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9387797,"INFECT AGNT BY DNA/RNA, NOS DIRECT PROBE, EACH REF",,87797,306,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9380313,MTB COMPLEX DIRECT,,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380524,VARICELLA-ZOSTER VIRUS PCR REF,,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380719,PARVOVIRUS B19 BY RAPID PCR REF,,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380748,"EHRLICHIA/ANAPLASMA PCR, B REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380766,"WEST NILE VIRUS PCR, P REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380821,LEGIONELLA PCR REF,,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380861,MYCOPLASMA HOMINIS PCR REF,,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380862,"UREAPLASMA SP, MOL DET, PCR REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9387798,INFECT AGNT NOS AMP PROBE REF,,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380146,AMPL PROBE EA ORG,,87798,306,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9380334,FLU A PANEL BY PCR,,87798,306,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9380715,"EPS-BARR VIRUS PCR, QNT, B REF",,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9380727,"BK VIRUS PCR, QUANT, P REF",,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9387799,INFECT AGNT NOS QNT EA ORG REF,,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9387801,INF AGNT AG NUCL ACID MULT ORG AMP PROB REF,,87801,306,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9386308,INFECTIOUS AGNT ANTIGN FLU A/B,,87804,306,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9387420,RESPIRATORY SYNCYTIAL VIRUS,,87807,306,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9380790,HIV-1 PHENOTYPIC RESIST PREDIC REF,,87900,306,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9385535,LABORATORY TEST REF,,87900,306,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9385556,LABORATORY TEST REF,,87900,306,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9387192,LABORATORY TEST REF,,87900,306,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9380789,"HIV-1 GENOTYPIC DRUG RESIST, P REF",,87901,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9382089,LABORATORY TEST REF,,87901,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9382538,LABORATORY TEST REF,,87901,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9387901,LABORATORY TEST REF,,87901,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9380760,HEPATITIS C GENOTYPING REF,,87902,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9387902,HEPATITS C VIRS RNA GENOTYP RF,,87902,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9383588,LABORATORY TEST REF,,87903,306,"$1,950.00 ","$1,950.00 ",$546.00 ,"$1,784.25 ","$1,365.00 ","$1,632.15 ","$1,784.25 ","$1,784.25 ","$1,784.25 ",$718.58 ,"$1,170.00 ",$585.00 ,"$1,755.00 ","$1,462.50 ","$1,560.00 ","$1,618.50 "
Hoopeston Regional Hlth Center,9383587,LABORATORY TEST REF,,87904,306,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9389321,"SEMEN ANAL, SPERM DETECTION",,89321,306,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9380241,POST VASECTOMY,,89321,306,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9381135,ID BY NUCLEIC ACID PROBE (EACH),,87150,306,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9380248,PHENOTYPE MIC SENSITIVITY,,87186,306,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9380233,C DIFFICILE TOXIN,,87324,306,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9380234,INFLUENZA A,,87400,306,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9387538,LABORATORY TEST REF,,87538,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380235,INFLUENZA B,,87400,306,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9380250,Bordetella Pertussis/parapertussis Pcr Mml Ref,,87801,306,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9387906,LABORATORY TEST REF,,87906,306,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9381464,CPT-AFB 10 DURG MIC PLUS 87181-90 (NAT'L JEWISH) REF,,87181,306,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381465,CPT-AFB 10 DRUG MIC RIF/ETHAM. 87186-90 (NAT'L JEWISH) REF,,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9381454,MYCOPLASMA PNEUMONIAE DNA,,87581,306,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,8381467,BORDETELLA PERTUSSIS DNA,,87798,306,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9381467,BORDETELLA PERTUSSIS DNA,,87798,306,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9381471,HELICOBACTER PYLORI CULTURE AND SUSC REF,,87081,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381475,OVA AND PARASITE SMEAR REF,,87497,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9381476,"CMV DNA DETEC/QUANT, P REF",,87497,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9381478,"CRYPTOCOCCUS AG TITER, LFA, S REF",,87899,306,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9381486,HHV-6A AND HHV-6B REF,,87533,306,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9381493,"VIRUS ISOL; SHELL VIAL TECHNIQUE, EACH VIRUS REF",,87254,306,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9380621,LAB/PATH TESTING,,87633,306,"$2,600.00 ","$2,600.00 ",$728.00 ,"$2,379.00 ","$1,820.00 ","$2,176.20 ","$2,379.00 ","$2,379.00 ","$2,379.00 ",$958.10 ,"$1,560.00 ",$780.00 ,"$2,340.00 ","$1,950.00 ","$2,080.00 ","$2,158.00 "
Hoopeston Regional Hlth Center,9381539,HCV GENOTYPE RESOLUTION REF,,87902,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9381550,"THROMBOPLASTIN TIME, PTL (PTT)-SUBSTITUTION/INCUBATED",,85732,306,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9380222,"MACROSCOPIC EXAM, ARTHROPOD",,87168,306,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9381555,HCV RNA GENOTYPE 3 NS5A DRUG RESIST REF,,87902,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9381558,HCV RNA GENOTYPE 1 NS5A DRUG RESIST REF,,87902,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9381570,LABORATORY SERVICE,,87538,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381577,"HERPES SIMPLEX VIRUS, PCR REF",,87529,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381578,"TOXOPLASMA GONDII, PCS REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381582,ACTINO/MYCO ID-CPT 87158 U OF TEXAS REF,,87158,306,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9381583,ACTINO/MYCO SEQUENCING CPT 87153 U OF TEXAS REF,,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381584,HIV-DNA/RNA QUALITIVE DETECT BY PCR REF,,87535,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381595,CPT-HCVGE 87902 BILLING,,87902,306,"$1,220.00 ","$1,220.00 ",$341.60 ,"$1,116.30 ",$854.00 ,"$1,021.14 ","$1,116.30 ","$1,116.30 ","$1,116.30 ",$449.57 ,$732.00 ,$366.00 ,"$1,098.00 ",$915.00 ,$976.00 ,"$1,012.60 "
Hoopeston Regional Hlth Center,9381521,MALARIA ANTIGEN,,87899,306,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9380651,"VIRAL CULTURE, RESPIRATORY REF",,87252,306,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9380677,"M. TUBERCULOSIS COMPLEX, PCR REF",,87556,306,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9381626,TRICHOMONAS VGINALIS AMP RNA REF,,87661,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,8287801,RSV RNA,,87801,306,$465.00 ,$465.00 ,$130.20 ,$425.48 ,$325.50 ,$389.21 ,$425.48 ,$425.48 ,$425.48 ,$171.35 ,$279.00 ,$139.50 ,$418.50 ,$348.75 ,$372.00 ,$385.95
Hoopeston Regional Hlth Center,9381633,TRICHOMONAS RAPID ANTIGEN TEST,,87808,306,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381634,BACTERIAL VAGINOSIS SCREEN,,87905,306,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,9381694,"CPT-MENINGITIS PANEL, CSF",,87483,306,"$1,520.00 ","$1,520.00 ",$425.60 ,"$1,390.80 ","$1,064.00 ","$1,272.24 ","$1,390.80 ","$1,390.80 ","$1,390.80 ",$560.12 ,$912.00 ,$456.00 ,"$1,368.00 ","$1,140.00 ","$1,216.00 ","$1,261.60 "
Hoopeston Regional Hlth Center,9381699,"CPT-RSV AMPLIFIED PROBE, EACH ORGANISM",,87798,306,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9381698,CPT-INFLUENZA AND RSV PANEL,,87631,306,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,9381710,INFLUENZA RNA,,87502,306,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9381711,RSV RNA,,87801,306,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9381735,IADNA DNA/RNA RSV AMPLIFIED PROBE TECHNIQUE,,87634,306,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9381745,"NON TB MYCOBACTERIA BY PCR, REF",,87551,306,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9381728,"ASPERGILLUS AG, BAL, REF",,87305,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381746,"MUMPS RNA, QUANT PCR, REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381760,"FUNGITELL, S, REF",,87449,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381765,"HC T.VAGINALIS, AMPLIFIED RNA, REF",,87661,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381766,"GI PATHOGEN, AMPLIFIED PROBE, REF",,87507,306,"$1,670.00 ","$1,670.00 ",$467.60 ,"$1,528.05 ","$1,169.00 ","$1,397.79 ","$1,528.05 ","$1,528.05 ","$1,528.05 ",$615.40 ,"$1,002.00 ",$501.00 ,"$1,503.00 ","$1,252.50 ","$1,336.00 ","$1,386.10 "
Hoopeston Regional Hlth Center,9381767,"RESP PATHOGEN, AMPLIFIED PROBE, REF",,87633,306,"$1,670.00 ","$1,670.00 ",$467.60 ,"$1,528.05 ","$1,169.00 ","$1,397.79 ","$1,528.05 ","$1,528.05 ","$1,528.05 ",$615.40 ,"$1,002.00 ",$501.00 ,"$1,503.00 ","$1,252.50 ","$1,336.00 ","$1,386.10 "
Hoopeston Regional Hlth Center,9381768,"UNSPECIFIED ORGANISM, AMPLIFIED PROBE, REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381771,CRYPTOCOCCAL ANTIGEN OR TITER,,87899,306,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9381015,"CULTURE REFER FOR ID, MYCOBACTERIUM REF",,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381035,BACTERIAL DETECTION BY PCR REF,,87801,306,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9381017,"CULTURE, TYPING; IMMUNOFLUORESCENT METHOD",,87140,306,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9381018,"IDENTIFICATION BY NUCLEIC ACID SEQUENCING, EACH",,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381019,"IMMUNOLOGIC METHOD, OTHER THAN IMMUNOFLUORESCENT",,87147,306,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9381020,"CULTURE, FUNGI, DEFINITIVE IDENTIFICATION, EACH",,87107,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381021,"CULTURE, MYCOBACTERIAL, DEFINITIVE, EACH",,87118,306,$58.00 ,$58.00 ,$16.24 ,$53.07 ,$40.60 ,$48.55 ,$53.07 ,$53.07 ,$53.07 ,$21.37 ,$34.80 ,$17.40 ,$52.20 ,$43.50 ,$46.40 ,$48.14
Hoopeston Regional Hlth Center,9381022,"IDENTIFICATION BY NUCLEIC ACID, DIRECT PROBE, EACH",,87149,306,$80.00 ,$80.00 ,$22.40 ,$73.20 ,$56.00 ,$66.96 ,$73.20 ,$73.20 ,$73.20 ,$29.48 ,$48.00 ,$24.00 ,$72.00 ,$60.00 ,$64.00 ,$66.40
Hoopeston Regional Hlth Center,9381023,"IDENTIFICATION BY NUCLEIC ACID, AMPLIFIED PROBE, EACH",,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381024,"IDENTIFICATION, OTHER METHODS",,87158,306,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9381025,"SUSCEPTIBILITY STUDIES, ANTIMICROBIAL AGENT, PER AGENT",,87181,306,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381026,"DISK METHOD, PER PLATE",,87184,306,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9381027,"ENZYME DETECTION, PER ENZYME",,87185,306,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381028,MIC EACH ANTIMICROBIAL; PER PLATE,,87187,306,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9381029,"MYCOBACTERIA, PROPORTION METHOD, EACH AGENT",,87190,306,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9381778,"GARNERELLA VAGINALIS BY RT, PCR, REF",,87511,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381780,"STAPHYLOCOCCUS AUREUS BY RT, PCR, REF",,87640,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381781,"CANDIDA RT PCR, REF",,87481,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381059,BORDETELLA BY PCR,,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381070,SUSCEPTIBILTY SUTDY EA AGNT RF,,87188,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381071,SUSCEPTIBILTY SUTDY EA AGNT RF,,87188,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381072,SUSCEPTIBILTY SUTDY EA AGNT RF,,87188,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381073,SUSCEPTIBILTY SUTDY EA AGNT RF,,87188,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381074,"SUSCEPTIBILITY STUDY, PER PLATE RF",,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9381075,AFB IDENTIFICATION BY NUCLEIC ACID SEQ. RF,,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381080,"VIRAL CULTURE AND ID, REF",,87253,306,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9381076,"CPT-KB SUSCEPTIBILITY STUDIES, PER AGENT",,87181,306,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9381077,"CPT-ETEST SUSCEPTIBILITY STUDIES, PER AGENT",,87181,306,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9381081,CPT-87798-GPP-INF. AGENT DETC. BY AMP. PROBE,,87798,306,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9381082,"CPT-87493-GPP-C DIFF, TOXIN GENE, AMP PROBE",,87493,306,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9381068,CPT-ID BY NUCLEIC ACID PROBE (U OF TEXAS),,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381097,CPT-AFB MIC SUSCEPT 87186-90 (NAT'L JEWISH) 1/1,,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9381098,CPT-AFB MIC SUSCEPT 87186-90 (NAT'L JEWISH) 1/1,,87186,306,$35.00 ,$35.00 ,$9.80 ,$32.03 ,$24.50 ,$29.30 ,$32.03 ,$32.03 ,$32.03 ,$12.90 ,$21.00 ,$10.50 ,$31.50 ,$26.25 ,$28.00 ,$29.05
Hoopeston Regional Hlth Center,9381099,"CPT-HBRP AMPLIFIED PROBE, EACH REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381104,"CPT-HBRPB AMPLIFIED PROBE, EACH REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381108,CPT-HPAGS HISTO ANTIGEN DETECTION REF,,87385,306,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9381109,CPT-HPAGU HISTO ANTIGEN DETECTION REF,,87385,306,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9381110,CPT-LCMV-CMV AMPLIFIED PROBE REF,,87496,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381114,CPT-UCMV AMPLIFIED PROBEááá REF,,87496,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381124,LABORATORY SERVICES,,87899,306,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9381789,"GROUP B STREP (GBS) BY RT, PCR, REF",,87653,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381763,"BETA STREP GROUP B BY PCR, PRENATAL",,87150,306,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9381764,"BETA STREP GROUP B BY PCR, LABOR & DELIVERY",,87653,306,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9381803,"ENTEROVIRUS PCR, REF.",,87498,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381130,"CHIKUNGUNYA VIRUS RNA, QUAL REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381137,"HISTOOPLASMA AG, RESULT REF",,87385,306,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9381145,"BK VIRUS QUANTITATIVE, PCR, U REF",,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9381146,LEGIONELLA CULTURE REF,,87081,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9381147,"HERPES SIMPLEX (HSV) PCR, B REV",,87529,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381148,PNEUMOCYSTIS JIROVECI PCR REF,,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381151,IDENT-BACTERIAL IDENTIFICATION REF,,87077,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381152,"IDENT-ID MALDI-TOF MASS SPEC, AEROBE REF",,87077,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381153,IDENT-IDENTIFICATION BY COMMERCIAL KIT REF,,87077,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381154,IDENT-IDENTIFICATION OF STAPHYLOCOCCUS REF,,87077,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381155,IDENT-IDENTIFICATION OF STREPTOCOCCUS REF,,87077,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381156,"IDENT-SEROLOGIC AGGLUT METHOD 2, IDENT REF",,87147,306,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9381157,"IDENT-SEROLOGIC AGGLUT METHOD 3, IDENT REF",,87147,306,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9381158,ANIDE-ANAEROBE ID BY SEQUENCING REF,,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381159,"ANIDE-ID MALDI-TOF MASS SPEC, ANAEROBE REF",,87076,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381160,"FUNID-CULTURE, FUNGI, DEFINITIVE IDENTICATION REF",,87107,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381162,"FUNID-FUNGAL IDENTIFICATION, PANEL A REF",,87107,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381163,"FUNID-FUNGAL IDENTIFICATION, PANEL B REF",,87107,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381165,"FUNID-ID -TOF MASS SPEC, YEAST REF",,87106,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381166,FUNID-IDENTIFICATION HISTO/BLASTO REF,,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381167,"FUNID-MICROBIAL PROBE, FUNGUS IDENTIFICATION REF",,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381168,"FUNID-YEAST IDENTIFICATION, PANEL A REF",,87107,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381169,"FUNID-YEAST IDENTIFICATION, PANEL B REF",,87107,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381170,"FUNID-YEAST IDENTIFICATION, PANEL C REF",,87106,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381171,"FUNID-YEAST IDENTIFICATION, PANEL D REF",,87106,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381172,"FUNID-D2 FUNGAL SEQUENCING, IDENTFICATION REF",,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381173,"CTBID-ID MYCOBACTERIUM, OTHER METHODS REF",,87158,306,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9381174,"CTBID-IDENTIFICATION, MTB SPECIATION, PCR REF",,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381175,"CTBID-MTB PZA CONFIRM, PCNA SEQUENCE REF",,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381176,"CTBID-MYCOBACERIUM IDENTIFICATION, SEQUENCING REF",,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381177,"CTBID-MYCOBACTERIA PROBE ID, BROTH REF",,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381178,"CTBID-MYCOBACTERIA PROBE ID, SOLID REF",,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381179,"CTBID-SUSCP, MTB MOP, 1 DRUG REF",,87190,306,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9381180,ZMMLS-2-KPC AND NDM PCR REF,,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381181,ZMMLS-CARBAPENEMASE DETEC. VIA HODGE REF,,87185,306,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381182,ZMMLS-CARBAPENEMASE DETEC. CARBA NP TEST REF,,87185,306,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381183,"ZMMLS-SUSCEPTIBILITY PER DRUG, NON ROUTINE REF",,87181,306,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381184,MMLSA-ANAEROBIC SUSCEPT PER AGENT REF,,87181,306,$19.00 ,$19.00 ,$5.32 ,$17.39 ,$13.30 ,$15.90 ,$17.39 ,$17.39 ,$17.39 ,$7.00 ,$11.40 ,$5.70 ,$17.10 ,$14.25 ,$15.20 ,$15.77
Hoopeston Regional Hlth Center,9381185,LEGI-AEROBE IDENTIFICATION BY SEQUENCING REF,,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9381186,"LEGI-ID MALDI-TOF MASS SPEC, LEGIONELLA REF",,87077,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381187,IDENT-ADDITIONAL IDENTIFICATION PROCEDURE REF,,87077,306,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,9381164,"FUNID-ID MALDI-TOF MASS SPEC, FUNGI REF",,87107,306,$41.00 ,$41.00 ,$11.48 ,$37.52 ,$28.70 ,$34.32 ,$37.52 ,$37.52 ,$37.52 ,$15.11 ,$24.60 ,$12.30 ,$36.90 ,$30.75 ,$32.80 ,$34.03
Hoopeston Regional Hlth Center,9381834,"CRYPTOSPORIDIUM AG, F, REF",,87328,306,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9381198,PNEUMOCYSTIS JIORVECI PCR REF,,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9381848,"C. DIFFICILE CULT, REF",,87493,306,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9381859,"C. DIFFICILE TOXINS A AND B, REF",,87324,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381871,"BABESIA SPECIES, PCR, B, REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381886,"MYCOPLASMA GENITALIUM PCR, REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381910,"MENINGITIS/ENCEPH PATHOGEN PANEL, PCR, CSF, REF",,87483,306,"$1,670.00 ","$1,670.00 ",$467.60 ,"$1,528.05 ","$1,169.00 ","$1,397.79 ","$1,528.05 ","$1,528.05 ","$1,528.05 ",$615.40 ,"$1,002.00 ",$501.00 ,"$1,503.00 ","$1,252.50 ","$1,336.00 ","$1,386.10 "
Hoopeston Regional Hlth Center,9381923,"HEV RNA DETECT/QUANT, S, REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381929,"IGP, COBAS HPV 16, REF",,87624,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381933,HEP C VIRAL DNA DRUG RESISTANCE REF,,87902,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9381952,"HERPES VIRUS 8 DNA, QNT, REF",,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9381963,C. DIFFICILE TOXIN EIA,,87324,306,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9381966,"CLOST DIFF TOXIN, REF",,87324,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381978,"C.DIFFICILE TOXIN, REF",,87324,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9381992,"ADENOVIRUS PCR, REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381988,"HIV-2 RNA QUANT, REF",,87539,306,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,9381998,"HEP D VIRUS RNA, QN, REAL TIME, PCR, REF",,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9382189,"COXIELLA BURNETII (Q FEVER), MOL DET PCR, BLD REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382191,LABORATORY TEST REF,,87491,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382334,"HIV-1 QNT BY NAAT, REF",,87536,306,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9382304,COVID,,87635,306,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9382378,"SARS-COV-2-RNA, PCR",,87635,306,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9382427,"LYME DIS DNA AMP PROBE, REF",,87476,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382429,"JC VIRUS, MOLECULAR DETECTION, PCR, SPINAL FLUID, REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382448,"STREPTOCOCCUS PNEUMONIAE AG, U, REF",,87899,306,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9382453,"HEPATITIS D VIRUS RNA, QN, RT, PCR, REF",,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9382467,"SARS-CoV-2, NAA, REF",,U0003,306,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9382468,HISTOPLASMA QN AG,,87385,306,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,9382475,"FUNGUS CULTURE, REF",,87101,306,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9382481,"HIV1 GENOTYPE/INTEGRASE, REF",,87901,306,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9382499,"HEP E VIRUS BY QUANT PCR, REF",,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9382535,SARS-COV-2/FLU/RSV,,0241U,306,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9382537,SARS-COV-2/FLU,,0240U,306,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,8287635,SARS-COV-2 COVID-19 AMP PRB,,87635,306,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9382587,"PERTUSSIS, REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382608,"LEGIONELLA AG, U, REF",,87899,306,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9380023,INFEC AGEN DETEC AMPLI PROBE,,U0005,306,$90.00 ,$90.00 ,$25.20 ,$82.35 ,$63.00 ,$75.33 ,$82.35 ,$82.35 ,$82.35 ,$33.17 ,$54.00 ,$27.00 ,$81.00 ,$67.50 ,$72.00 ,$74.70
Hoopeston Regional Hlth Center,9382682,"M. GENITALIUM NAA, URINE, REF",,87563,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382686,"ASPERGILLUS ANTIGEN, S REF",,87305,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382581,"EPSTEIN-BARR VIRUS DNA, QUANT, PCR, B REF",,87799,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9382816,"FUNGITELL (1-3)- BETA-D-GLUCAN, S [REF]",,87449,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9382827,TICK (AND OTHER ARTHROPODS) ID,,87168,306,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,9382856,"HIV-1 GENOTYPIC INTEGASE INHIBITOR DRUG RESIS, P, REF",,87906,306,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9382868,"MYCOBACTERIA CULTURE, CONCENTRATION",,87015,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9382870,ID BY 16S SEQUENCING,,87153,306,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9382872,"ID, MTB SPECIATION, PCR",,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382873,MYCOBACTERIAL PROBE IDENT,,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382874,"MYCOBACTERIAL PROBE IDENT, BROTH",,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382875,"MYCOBACTERIAL CULTURE, CONCENTRATION",,87015,306,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9382877,"ID, MTB COMPLEX RAPID PCR",,87150,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382858,"HCV RNA QUANT W/RFX TO GENOTYPE, B [REF]",,87522,306,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9382971,"MYCOPLASMA GENITALIUM MOLECULAR PCR, REF",,87563,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9383107,"GIARDIA AG, EIA, STOOL, REF",,87329,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9383139,"TROPHERYMA WHIPPLEI PCR, B, REF",,87798,306,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9383165,"LEGIONELLA AG, EIA, URINE, REF",,87449,306,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,8287651,STRA-GROUP A STREP (POC),,87651,306,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9381231,"CPT-RPP-RESPIRATORY VIRUS, PROBE, 12-25 TARGETS",,0202U,306,"$1,650.00 ","$1,650.00 ",$462.00 ,"$1,509.75 ","$1,155.00 ","$1,381.05 ","$1,509.75 ","$1,509.75 ","$1,509.75 ",$608.03 ,$990.00 ,$495.00 ,"$1,485.00 ","$1,237.50 ","$1,320.00 ","$1,369.50 "
Hoopeston Regional Hlth Center,9381233,CPT-HPV HIGH RISK TYPES,,87624,306,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,87635,SARS-COV-2 COVID-19 AMP PRB,,87635,306,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,87220,TISSUE EXAM BY KOH,,87220,306,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,Q0112,Potassium hydroxide preps,,Q0112,306,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,87880,STREP A ASSAY W/OPTIC,,87880,306,$82.00 ,$82.00 ,$22.96 ,$75.03 ,$57.40 ,$68.63 ,$75.03 ,$75.03 ,$75.03 ,$30.22 ,$49.20 ,$24.60 ,$73.80 ,$61.50 ,$65.60 ,$68.06
Hoopeston Regional Hlth Center,87801,"DETECT AGENT, MULT ORGS, DNA, AMP",,87801,306,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,87808,TRICHOMONAS ASSAY W/OPTIC,,87808,306,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,87905,INFECT AGENT ENZYMATIC ACTIVITY NON-VIRUS,,87905,306,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9381199,"URINIE INDICANS QUAL, REF",,81005,307,$9.00 ,$9.00 ,$2.52 ,$8.24 ,$6.30 ,$7.53 ,$8.24 ,$8.24 ,$8.24 ,$3.32 ,$5.40 ,$2.70 ,$8.10 ,$6.75 ,$7.20 ,$7.47
Hoopeston Regional Hlth Center,9389052,"CELL COUNT, MISC BODY FLUID",,89050,309,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9380221,CRYSTAL ID BY LIGHT MICROSCOPY REF,,89060,309,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9389060,CRYSTAL ID BY LIGHT MICROSCOPY,,89060,309,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9389050,"CELL COUNT, MISC BODY FLUID",,89050,309,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9380627,"CRYSTALS, TISSUE",,89060,309,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9381411,COMPARATIVE ANALY USING STR MARKERS REF,,81265,310,$930.00 ,$930.00 ,$260.40 ,$850.95 ,$651.00 ,$778.41 ,$850.95 ,$850.95 ,$850.95 ,$342.71 ,$558.00 ,$279.00 ,$837.00 ,$697.50 ,$744.00 ,$771.90
Hoopeston Regional Hlth Center,9385096,BONE MARROW SMEAR INTER REF,,85097,310,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9387140,DRA/LEGIONELLA PNEUMOPHILA,,87300,310,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9388106,"CYTOPATH FLUIDS/WASHINGS/BRUSHINGS, SMEARS W/INTERP",,88104,310,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9388141,"CYTOPATH, CV, INTERPRET",,88141,310,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9389180,BRONCIAL SPECIMENS W/STAIN,,88162,310,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9388150,DX CYTOPATH-B CX/VAG,,88164,310,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9388172,"EVAL. FOR ADEQUACY, INITIAL",,88172,310,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9388173,FNA EVA INTER-REPORT,,88173,310,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9388264,CHROM ANALYSIS; 20-25 CELLS RF,,88264,310,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9388267,CHROMO ANA AMNIO FLUID REF,,88267,310,$750.00 ,$750.00 ,$210.00 ,$686.25 ,$525.00 ,$627.75 ,$686.25 ,$686.25 ,$686.25 ,$276.38 ,$450.00 ,$225.00 ,$675.00 ,$562.50 ,$600.00 ,$622.50
Hoopeston Regional Hlth Center,9388283,CHRM ANALYS ADNL SPEC BNDNG RF,,88283,310,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9388289,CHROM ADNL HI RES STUDY REF,,88289,310,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9388400,SURGICAL PATHOLOGY LEVEL -1,,88300,310,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9388402,SURGICAL PATHOLOGY LEVEL-II,,88302,310,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9388404,SURGI-PATHO LEVEL-III,,88304,310,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9385630,LEVEL IV -SURGICAL PATH REF,,88305,310,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9388405,SURGICALPATHOLOGY LEVEL-IV,,88305,310,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,9388403,LEVEL IV -SURGICAL PATH,,88305,310,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9388407,SURGICL PATHOLOGY LEVEL-V,,88307,310,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9388307,SURGICAL PATHOLOGY LEVEL-V REF,,88307,310,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9388409,SURGICAL PATHOLOGYLEVEL-VI,,88309,310,$465.00 ,$465.00 ,$130.20 ,$425.48 ,$325.50 ,$389.21 ,$425.48 ,$425.48 ,$425.48 ,$171.35 ,$279.00 ,$139.50 ,$418.50 ,$348.75 ,$372.00 ,$385.95
Hoopeston Regional Hlth Center,9388411,DECALCIFICATION PROCEDURE,,88311,310,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9388316,SPECIAL STAIN-FROZN SECTIN REF,,88314,310,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9385710,DETRMINATV HISTO/CYTO TO ID RF,,88319,310,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9388319,DETERMINATIVE HISTO/CYTO TO ID,,88319,310,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9388431,"FROZEN SECTION, 1ST TISS BLOCK",,88331,310,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9388432,"FROZEN SECTION, ADL TISS BLOCK",,88332,310,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9388333,INTRAOPERATIVE CYTOPATHOLOGY,,88333,310,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9388348,ELECTRON MICROSCOPY REF,,88348,310,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9388449,ELECTRON MICROSCPY DX,,88348,310,"$2,310.00 ","$2,310.00 ",$646.80 ,"$2,113.65 ","$1,617.00 ","$1,933.47 ","$2,113.65 ","$2,113.65 ","$2,113.65 ",$851.24 ,"$1,386.00 ",$693.00 ,"$2,079.00 ","$1,732.50 ","$1,848.00 ","$1,917.30 "
Hoopeston Regional Hlth Center,9388360,IN SITU HYBRIDIZATN EA PRBE RF,,88365,310,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9381444,NBS-SCID SCRN REF,,81479,310,"$1,380.00 ","$1,380.00 ",$386.40 ,"$1,262.70 ",$966.00 ,"$1,155.06 ","$1,262.70 ","$1,262.70 ","$1,262.70 ",$508.53 ,$828.00 ,$414.00 ,"$1,242.00 ","$1,035.00 ","$1,104.00 ","$1,145.40 "
Hoopeston Regional Hlth Center,9381481,"DIAGNOSTIC TESTING, XOMEDXPLUS REF",,81415,310,"$19,120.00 ","$19,120.00 ","$5,353.60 ","$17,494.80 ","$13,384.00 ","$16,003.44 ","$17,494.80 ","$17,494.80 ","$17,494.80 ","$7,045.72 ","$11,472.00 ","$5,736.00 ","$17,208.00 ","$14,340.00 ","$15,296.00 ","$15,869.60 "
Hoopeston Regional Hlth Center,9381482,WHOLE EXOME SEQUENCE ANALYSIS REF,,81460,310,"$5,150.00 ","$5,150.00 ","$1,442.00 ","$4,712.25 ","$3,605.00 ","$4,310.55 ","$4,712.25 ","$4,712.25 ","$4,712.25 ","$1,897.78 ","$3,090.00 ","$1,545.00 ","$4,635.00 ","$3,862.50 ","$4,120.00 ","$4,274.50 "
Hoopeston Regional Hlth Center,9381496,LYNCH/COLORECTAL HIGH RISK PANEL REF,,81292,310,"$2,700.00 ","$2,700.00 ",$756.00 ,"$2,470.50 ","$1,890.00 ","$2,259.90 ","$2,470.50 ","$2,470.50 ","$2,470.50 ",$994.95 ,"$1,620.00 ",$810.00 ,"$2,430.00 ","$2,025.00 ","$2,160.00 ","$2,241.00 "
Hoopeston Regional Hlth Center,9381497,LYNCH/COLORECTAL HIGH RISK PANEL REF,,81294,310,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,9381498,LYNCH/COLORECTAL HIGH RISK PANEL REF,,81295,310,"$1,530.00 ","$1,530.00 ",$428.40 ,"$1,399.95 ","$1,071.00 ","$1,280.61 ","$1,399.95 ","$1,399.95 ","$1,399.95 ",$563.81 ,$918.00 ,$459.00 ,"$1,377.00 ","$1,147.50 ","$1,224.00 ","$1,269.90 "
Hoopeston Regional Hlth Center,9381499,LYNCH/COLORECTAL HIGH RISK PANEL REF,,81297,310,$850.00 ,$850.00 ,$238.00 ,$777.75 ,$595.00 ,$711.45 ,$777.75 ,$777.75 ,$777.75 ,$313.23 ,$510.00 ,$255.00 ,$765.00 ,$637.50 ,$680.00 ,$705.50
Hoopeston Regional Hlth Center,9381501,LYNCH/COLORECTAL HIGH RISK PANEL REF,,81317,310,"$2,710.00 ","$2,710.00 ",$758.80 ,"$2,479.65 ","$1,897.00 ","$2,268.27 ","$2,479.65 ","$2,479.65 ","$2,479.65 ",$998.64 ,"$1,626.00 ",$813.00 ,"$2,439.00 ","$2,032.50 ","$2,168.00 ","$2,249.30 "
Hoopeston Regional Hlth Center,9381502,LYNCH/COLORECTAL HIGH RISK PANEL REF,,81298,310,"$2,570.00 ","$2,570.00 ",$719.60 ,"$2,351.55 ","$1,799.00 ","$2,151.09 ","$2,351.55 ","$2,351.55 ","$2,351.55 ",$947.05 ,"$1,542.00 ",$771.00 ,"$2,313.00 ","$1,927.50 ","$2,056.00 ","$2,133.10 "
Hoopeston Regional Hlth Center,9381504,LYNCH/COLORECTAL HIGH RISK PANEL REF,,81300,310,$950.00 ,$950.00 ,$266.00 ,$869.25 ,$665.00 ,$795.15 ,$869.25 ,$869.25 ,$869.25 ,$350.08 ,$570.00 ,$285.00 ,$855.00 ,$712.50 ,$760.00 ,$788.50
Hoopeston Regional Hlth Center,9381206,LAB/PATH TESTING,,81206,310,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9380293,LAB/PATH TESTING,,81220,310,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9380294,LAB/PATH TESTING,,81221,310,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9380295,LAB/PATH TESTING,,81222,310,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9380296,LAB/PATH TESTING,,81223,310,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9380297,LAB/PATH TESTING,,81224,310,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9380291,LAB/PATH TESTING,,81240,310,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,9380292,LAB/PATH TESTING,,81241,310,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,9381241,LAB/PATH TESTING,,81241,310,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9381256,LAB/PATH TESTING,,81256,310,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9381270,LAB/PATH TESTING,,81270,310,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,9380287,LAB/PATH TESTING,,81382,310,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9380625,LAB/PATH TESTING,,81403,310,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9380289,LAB/PATH TESTING,,81479,310,"$1,380.00 ","$1,380.00 ",$386.40 ,"$1,262.70 ",$966.00 ,"$1,155.06 ","$1,262.70 ","$1,262.70 ","$1,262.70 ",$508.53 ,$828.00 ,$414.00 ,"$1,242.00 ","$1,035.00 ","$1,104.00 ","$1,145.40 "
Hoopeston Regional Hlth Center,9380626,LAB/PATH TESTING,,81511,310,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,9381527,"IMMFL ST; ADDNL AB, EACH (CROHN-PROM) REF",,88350,310,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381529,"IMMFL ST; ADDNL AB, EACH (SGI-PROM) REF",,88350,310,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381536,IMMUNOFLUORESCENCE EA ADDT ANTIBODY STAIN REF,,88350,310,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9388350,IMMUNOFLOURESCENCE EA ADDT SINGLE ANTIBODY STAIN,,88350,310,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,9381552,"MPN, CALR GENE MUTATION, EXON 9 REF",,81219,310,$485.00 ,$485.00 ,$135.80 ,$443.78 ,$339.50 ,$405.95 ,$443.78 ,$443.78 ,$443.78 ,$178.72 ,$291.00 ,$145.50 ,$436.50 ,$363.75 ,$388.00 ,$402.55
Hoopeston Regional Hlth Center,9380631,UTZID MOLEC PATH LVL 1 RESTR ENZ DIGEST REF,,81400,310,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9381207,BCR/ABL1 TRANSLOC; MINOR BREAKPT REF,,81207,310,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9381208,BCR/ABL1 TRANSLOC; OTHER BREAKPT REF,,81208,310,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,9381210,BRAF GENE ANALYSIS REF,,81210,310,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,9381211,"BRCA1, BRCA2 GENE ANAL; FULL SEQ REF",,81211,310,"$9,580.00 ","$9,580.00 ","$2,682.40 ","$8,765.70 ","$6,706.00 ","$8,018.46 ","$8,765.70 ","$8,765.70 ","$8,765.70 ","$3,530.23 ","$5,748.00 ","$2,874.00 ","$8,622.00 ","$7,185.00 ","$7,664.00 ","$7,951.40 "
Hoopeston Regional Hlth Center,9381212,"BRCA1, BRCA2 GENE ANAL; VARIANTS REF",,81212,310,"$1,760.00 ","$1,760.00 ",$492.80 ,"$1,610.40 ","$1,232.00 ","$1,473.12 ","$1,610.40 ","$1,610.40 ","$1,610.40 ",$648.56 ,"$1,056.00 ",$528.00 ,"$1,584.00 ","$1,320.00 ","$1,408.00 ","$1,460.80 "
Hoopeston Regional Hlth Center,9381213,"BRCA1, BRCA2 GENE ANAL;UNCOMM VAR REF",,81213,310,"$2,210.00 ","$2,210.00 ",$618.80 ,"$2,022.15 ","$1,547.00 ","$1,849.77 ","$2,022.15 ","$2,022.15 ","$2,022.15 ",$814.39 ,"$1,326.00 ",$663.00 ,"$1,989.00 ","$1,657.50 ","$1,768.00 ","$1,834.30 "
Hoopeston Regional Hlth Center,9381214,BRCA1 GENE ANAL; SEQ W/COMM D/D REF,,81214,310,"$4,220.00 ","$4,220.00 ","$1,181.60 ","$3,861.30 ","$2,954.00 ","$3,532.14 ","$3,861.30 ","$3,861.30 ","$3,861.30 ","$1,555.07 ","$2,532.00 ","$1,266.00 ","$3,798.00 ","$3,165.00 ","$3,376.00 ","$3,502.60 "
Hoopeston Regional Hlth Center,9381215,BRCA1 GENE ANAL; KNOWN FAM VAR REF,,81215,310,"$1,500.00 ","$1,500.00 ",$420.00 ,"$1,372.50 ","$1,050.00 ","$1,255.50 ","$1,372.50 ","$1,372.50 ","$1,372.50 ",$552.75 ,$900.00 ,$450.00 ,"$1,350.00 ","$1,125.00 ","$1,200.00 ","$1,245.00 "
Hoopeston Regional Hlth Center,9381216,BRCA2 GENE ANAL; FULL SEQ REF,,81216,310,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9381217,BRCA2 GENE ANAL; KNOWN FAM VAR REF,,81217,310,"$1,500.00 ","$1,500.00 ",$420.00 ,"$1,372.50 ","$1,050.00 ","$1,255.50 ","$1,372.50 ","$1,372.50 ","$1,372.50 ",$552.75 ,$900.00 ,$450.00 ,"$1,350.00 ","$1,125.00 ","$1,200.00 ","$1,245.00 "
Hoopeston Regional Hlth Center,9381220,CFTR GENE ANALYSIS REF,,81220,310,"$2,230.00 ","$2,230.00 ",$624.40 ,"$2,040.45 ","$1,561.00 ","$1,866.51 ","$2,040.45 ","$2,040.45 ","$2,040.45 ",$821.76 ,"$1,338.00 ",$669.00 ,"$2,007.00 ","$1,672.50 ","$1,784.00 ","$1,850.90 "
Hoopeston Regional Hlth Center,9381226,CPT-CYTOCHR P450 2D6 GENOTYPE REF,,81226,310,"$1,800.00 ","$1,800.00 ",$504.00 ,"$1,647.00 ","$1,260.00 ","$1,506.60 ","$1,647.00 ","$1,647.00 ","$1,647.00 ",$663.30 ,"$1,080.00 ",$540.00 ,"$1,620.00 ","$1,350.00 ","$1,440.00 ","$1,494.00 "
Hoopeston Regional Hlth Center,9381228,CGH MICROARRAY ANALY REF,,81228,310,"$3,600.00 ","$3,600.00 ","$1,008.00 ","$3,294.00 ","$2,520.00 ","$3,013.20 ","$3,294.00 ","$3,294.00 ","$3,294.00 ","$1,326.60 ","$2,160.00 ","$1,080.00 ","$3,240.00 ","$2,700.00 ","$2,880.00 ","$2,988.00 "
Hoopeston Regional Hlth Center,9381229,CGH MIRCOARRAY ANALY; SNP REF,,81229,310,"$4,640.00 ","$4,640.00 ","$1,299.20 ","$4,245.60 ","$3,248.00 ","$3,883.68 ","$4,245.60 ","$4,245.60 ","$4,245.60 ","$1,709.84 ","$2,784.00 ","$1,392.00 ","$4,176.00 ","$3,480.00 ","$3,712.00 ","$3,851.20 "
Hoopeston Regional Hlth Center,9381255,HEXA GENE ANALYSIS REF,,81255,310,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9381260,IKBKAP GENE ANALY REF,,81260,310,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9381261,IGH GENE REARR; AMP REF,,81261,310,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,9381262,IGH GENE REARR; DIR PROBE REF,,81262,310,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9381263,"IGH, VAR REG SOMATIC MUT ANALY REF",,81263,310,"$1,180.00 ","$1,180.00 ",$330.40 ,"$1,079.70 ",$826.00 ,$987.66 ,"$1,079.70 ","$1,079.70 ","$1,079.70 ",$434.83 ,$708.00 ,$354.00 ,"$1,062.00 ",$885.00 ,$944.00 ,$979.40
Hoopeston Regional Hlth Center,9381264,IGK GENE REARR ANALY REF,,81264,310,$690.00 ,$690.00 ,$193.20 ,$631.35 ,$483.00 ,$577.53 ,$631.35 ,$631.35 ,$631.35 ,$254.27 ,$414.00 ,$207.00 ,$621.00 ,$517.50 ,$552.00 ,$572.70
Hoopeston Regional Hlth Center,9381275,"KRAS GENE ANALY; CONDONS 12, 13 REF",,81275,310,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,9381292,MLH1 GENE ANAL; FULL SEQ REF,,81292,310,"$2,700.00 ","$2,700.00 ",$756.00 ,"$2,470.50 ","$1,890.00 ","$2,259.90 ","$2,470.50 ","$2,470.50 ","$2,470.50 ",$994.95 ,"$1,620.00 ",$810.00 ,"$2,430.00 ","$2,025.00 ","$2,160.00 ","$2,241.00 "
Hoopeston Regional Hlth Center,9381293,MLH1 GENE ANAL; KNOWN FAM VAR REF,,81293,310,"$1,320.00 ","$1,320.00 ",$369.60 ,"$1,207.80 ",$924.00 ,"$1,104.84 ","$1,207.80 ","$1,207.80 ","$1,207.80 ",$486.42 ,$792.00 ,$396.00 ,"$1,188.00 ",$990.00 ,"$1,056.00 ","$1,095.60 "
Hoopeston Regional Hlth Center,9381294,MLH1 GENE ANAL; DEL/DUP VAR REF,,81294,310,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,9381295,MSH2 GENE ANAL; FULL SEQ REF,,81295,310,"$1,530.00 ","$1,530.00 ",$428.40 ,"$1,399.95 ","$1,071.00 ","$1,280.61 ","$1,399.95 ","$1,399.95 ","$1,399.95 ",$563.81 ,$918.00 ,$459.00 ,"$1,377.00 ","$1,147.50 ","$1,224.00 ","$1,269.90 "
Hoopeston Regional Hlth Center,9381296,MSH2 GENE ANAL; KNOWN FAM VAR REF,,81296,310,"$1,350.00 ","$1,350.00 ",$378.00 ,"$1,235.25 ",$945.00 ,"$1,129.95 ","$1,235.25 ","$1,235.25 ","$1,235.25 ",$497.48 ,$810.00 ,$405.00 ,"$1,215.00 ","$1,012.50 ","$1,080.00 ","$1,120.50 "
Hoopeston Regional Hlth Center,9381297,MSH2 GENE ANAL; DEL/DUP VAR REF,,81297,310,$850.00 ,$850.00 ,$238.00 ,$777.75 ,$595.00 ,$711.45 ,$777.75 ,$777.75 ,$777.75 ,$313.23 ,$510.00 ,$255.00 ,$765.00 ,$637.50 ,$680.00 ,$705.50
Hoopeston Regional Hlth Center,9381298,MSH6 GENE ANAL; FULL SEQ REF,,81298,310,"$2,570.00 ","$2,570.00 ",$719.60 ,"$2,351.55 ","$1,799.00 ","$2,151.09 ","$2,351.55 ","$2,351.55 ","$2,351.55 ",$947.05 ,"$1,542.00 ",$771.00 ,"$2,313.00 ","$1,927.50 ","$2,056.00 ","$2,133.10 "
Hoopeston Regional Hlth Center,9381299,MSH6 GENE ANAL; KNOWN FAM VAR REF,,81299,310,"$1,230.00 ","$1,230.00 ",$344.40 ,"$1,125.45 ",$861.00 ,"$1,029.51 ","$1,125.45 ","$1,125.45 ","$1,125.45 ",$453.26 ,$738.00 ,$369.00 ,"$1,107.00 ",$922.50 ,$984.00 ,"$1,020.90 "
Hoopeston Regional Hlth Center,9381300,MSH6 GENE ANAL; DEL/DUP VAR REF,,81300,310,$950.00 ,$950.00 ,$266.00 ,$869.25 ,$665.00 ,$795.15 ,$869.25 ,$869.25 ,$869.25 ,$350.08 ,$570.00 ,$285.00 ,$855.00 ,$712.50 ,$760.00 ,$788.50
Hoopeston Regional Hlth Center,9381301,CPT-HNPCC SCREEN MML REF,,81301,310,"$1,390.00 ","$1,390.00 ",$389.20 ,"$1,271.85 ",$973.00 ,"$1,163.43 ","$1,271.85 ","$1,271.85 ","$1,271.85 ",$512.22 ,$834.00 ,$417.00 ,"$1,251.00 ","$1,042.50 ","$1,112.00 ","$1,153.70 "
Hoopeston Regional Hlth Center,9381302,MECP2 GENE ANALYSIS FULL SEQ REF,,81302,310,"$2,110.00 ","$2,110.00 ",$590.80 ,"$1,930.65 ","$1,477.00 ","$1,766.07 ","$1,930.65 ","$1,930.65 ","$1,930.65 ",$777.54 ,"$1,266.00 ",$633.00 ,"$1,899.00 ","$1,582.50 ","$1,688.00 ","$1,751.30 "
Hoopeston Regional Hlth Center,9381303,MECP2 GENE ANAL KNOWN VAR REF,,81303,310,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9381304,MECP2 GENE ALAY DEL/DUP VAR REF,,81304,310,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,9381317,PMS2 GENE ANAL; FULL SEQ REF,,81317,310,"$2,710.00 ","$2,710.00 ",$758.80 ,"$2,479.65 ","$1,897.00 ","$2,268.27 ","$2,479.65 ","$2,479.65 ","$2,479.65 ",$998.64 ,"$1,626.00 ",$813.00 ,"$2,439.00 ","$2,032.50 ","$2,168.00 ","$2,249.30 "
Hoopeston Regional Hlth Center,9381318,PMS2 GENE ANAL; KNOWN FAM VAR REF,,81318,310,"$1,320.00 ","$1,320.00 ",$369.60 ,"$1,207.80 ",$924.00 ,"$1,104.84 ","$1,207.80 ","$1,207.80 ","$1,207.80 ",$486.42 ,$792.00 ,$396.00 ,"$1,188.00 ",$990.00 ,"$1,056.00 ","$1,095.60 "
Hoopeston Regional Hlth Center,9381319,PMS2 GENE ANAL; DEL/DUP VAR REF,,81319,310,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,9381331,SNRPN/UBE3A MUT ANALYSIS REF,,81331,310,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9381332,CPT-SERPINA 1 (A1AT DEFIC) REF,,81332,310,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9381340,CPT-TRB T CELL RECEP GENE REARR REF,,81340,310,$840.00 ,$840.00 ,$235.20 ,$768.60 ,$588.00 ,$703.08 ,$768.60 ,$768.60 ,$768.60 ,$309.54 ,$504.00 ,$252.00 ,$756.00 ,$630.00 ,$672.00 ,$697.20
Hoopeston Regional Hlth Center,9381342,CPT-TRG T CELL RECEP GENE REARR REF,,81342,310,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,9381372,"HLA CLASS I TYPING, LOW RES, COMPL REF",,81372,310,"$1,610.00 ","$1,610.00 ",$450.80 ,"$1,473.15 ","$1,127.00 ","$1,347.57 ","$1,473.15 ","$1,473.15 ","$1,473.15 ",$593.29 ,$966.00 ,$483.00 ,"$1,449.00 ","$1,207.50 ","$1,288.00 ","$1,336.30 "
Hoopeston Regional Hlth Center,9381373,"HLA CLASS I TYPING, LOW RES, 1 LOC REF",,81373,310,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9381374,"HLA CLASS I TYPING, LOW RES 1 AG REF",,81374,310,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9381221,CFTR GENE; KNOWN FAM VAR REF,,81221,310,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9381222,CFTR GENE ; DEL/DUP VARIANTS REF,,81222,310,"$1,740.00 ","$1,740.00 ",$487.20 ,"$1,592.10 ","$1,218.00 ","$1,456.38 ","$1,592.10 ","$1,592.10 ","$1,592.10 ",$641.19 ,"$1,044.00 ",$522.00 ,"$1,566.00 ","$1,305.00 ","$1,392.00 ","$1,444.20 "
Hoopeston Regional Hlth Center,9381224,CFTR GENE; INTRON 8 POLY-T ANALY REF,,81224,310,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9381581,"BCR/ABL1 MUTATION, SEQ REF",,81170,310,"$1,200.00 ","$1,200.00 ",$336.00 ,"$1,098.00 ",$840.00 ,"$1,004.40 ","$1,098.00 ","$1,098.00 ","$1,098.00 ",$442.20 ,$720.00 ,$360.00 ,"$1,080.00 ",$900.00 ,$960.00 ,$996.00
Hoopeston Regional Hlth Center,9381587,"PROTHROMBIN G20210A MUTATION, B REF",,81240,310,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,9381588,NRAS GENE VARIANTS EXON 2&3 REF,,81311,310,"$1,180.00 ","$1,180.00 ",$330.40 ,"$1,079.70 ",$826.00 ,$987.66 ,"$1,079.70 ","$1,079.70 ","$1,079.70 ",$434.83 ,$708.00 ,$354.00 ,"$1,062.00 ",$885.00 ,$944.00 ,$979.40
Hoopeston Regional Hlth Center,9381589,"LUNG CA PANEL, GEN PATH REF",,81276,310,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,9381601,ALPHA-GLOBIN GENE ANALYSIS REF,,81257,310,$410.00 ,$410.00 ,$114.80 ,$375.15 ,$287.00 ,$343.17 ,$375.15 ,$375.15 ,$375.15 ,$151.09 ,$246.00 ,$123.00 ,$369.00 ,$307.50 ,$328.00 ,$340.30
Hoopeston Regional Hlth Center,9381380,HLA B HIGH RESOLUTION REF,,81380,310,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,9381622,NEXT GEN SEQ PANEL REF,,81442,310,"$8,570.00 ","$8,570.00 ","$2,399.60 ","$7,841.55 ","$5,999.00 ","$7,173.09 ","$7,841.55 ","$7,841.55 ","$7,841.55 ","$3,158.05 ","$5,142.00 ","$2,571.00 ","$7,713.00 ","$6,427.50 ","$6,856.00 ","$7,113.10 "
Hoopeston Regional Hlth Center,9381631,"XOMEDX PLUS TRIO, REF",,81416,310,"$48,000.00 ","$48,000.00 ","$13,440.00 ","$43,920.00 ","$33,600.00 ","$40,176.00 ","$43,920.00 ","$43,920.00 ","$43,920.00 ","$17,688.00 ","$28,800.00 ","$14,400.00 ","$43,200.00 ","$36,000.00 ","$38,400.00 ","$39,840.00 "
Hoopeston Regional Hlth Center,9381632,"BRCA1/BRCA2 GENES, FULL GENE ANALYSIS, REF",,81162,310,"$7,300.00 ","$7,300.00 ","$2,044.00 ","$6,679.50 ","$5,110.00 ","$6,110.10 ","$6,679.50 ","$6,679.50 ","$6,679.50 ","$2,690.05 ","$4,380.00 ","$2,190.00 ","$6,570.00 ","$5,475.00 ","$5,840.00 ","$6,059.00 "
Hoopeston Regional Hlth Center,9381636,"ONCOHEME NGS FOR HEMATOLOGIC CANCER, REF",,81450,310,"$3,040.00 ","$3,040.00 ",$851.20 ,"$2,781.60 ","$2,128.00 ","$2,544.48 ","$2,781.60 ","$2,781.60 ","$2,781.60 ","$1,120.24 ","$1,824.00 ",$912.00 ,"$2,736.00 ","$2,280.00 ","$2,432.00 ","$2,523.20 "
Hoopeston Regional Hlth Center,9381642,"MLH1 HYPERMETHYLATION, REF",,81288,310,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,9381643,"CULTURE 05, REF",,88239,310,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9381644,"MITOCHONDRIAL GENOME SEQ, DEL ANAL, REF",,81465,310,"$3,740.00 ","$3,740.00 ","$1,047.20 ","$3,422.10 ","$2,618.00 ","$3,130.38 ","$3,422.10 ","$3,422.10 ","$3,422.10 ","$1,378.19 ","$2,244.00 ","$1,122.00 ","$3,366.00 ","$2,805.00 ","$2,992.00 ","$3,104.20 "
Hoopeston Regional Hlth Center,9381655,"PDGFRA MUTATION ANALYSIS, REF",,81314,310,"$1,320.00 ","$1,320.00 ",$369.60 ,"$1,207.80 ",$924.00 ,"$1,104.84 ","$1,207.80 ","$1,207.80 ","$1,207.80 ",$486.42 ,$792.00 ,$396.00 ,"$1,188.00 ",$990.00 ,"$1,056.00 ","$1,095.60 "
Hoopeston Regional Hlth Center,9381658,"DYSTROPHINOPATHY VIA DMD DE/DUP, REF",,81161,310,"$1,120.00 ","$1,120.00 ",$313.60 ,"$1,024.80 ",$784.00 ,$937.44 ,"$1,024.80 ","$1,024.80 ","$1,024.80 ",$412.72 ,$672.00 ,$336.00 ,"$1,008.00 ",$840.00 ,$896.00 ,$929.60
Hoopeston Regional Hlth Center,9381662,"LQTS SEQUENCING, REF",,81414,310,"$2,340.00 ","$2,340.00 ",$655.20 ,"$2,141.10 ","$1,638.00 ","$1,958.58 ","$2,141.10 ","$2,141.10 ","$2,141.10 ",$862.29 ,"$1,404.00 ",$702.00 ,"$2,106.00 ","$1,755.00 ","$1,872.00 ","$1,942.20 "
Hoopeston Regional Hlth Center,9381663,"NEXT GEN GASTRIC SEQ PANEL, REF",,81445,310,"$2,390.00 ","$2,390.00 ",$669.20 ,"$2,186.85 ","$1,673.00 ","$2,000.43 ","$2,186.85 ","$2,186.85 ","$2,186.85 ",$880.72 ,"$1,434.00 ",$717.00 ,"$2,151.00 ","$1,792.50 ","$1,912.00 ","$1,983.70 "
Hoopeston Regional Hlth Center,9381665,"VITREORETINOPATHY PANEL, REF",,81434,310,"$2,390.00 ","$2,390.00 ",$669.20 ,"$2,186.85 ","$1,673.00 ","$2,000.43 ","$2,186.85 ","$2,186.85 ","$2,186.85 ",$880.72 ,"$1,434.00 ",$717.00 ,"$2,151.00 ","$1,792.50 ","$1,912.00 ","$1,983.70 "
Hoopeston Regional Hlth Center,9381666,"CANCER TYPE ID, REF",,81540,310,"$15,000.00 ","$15,000.00 ","$4,200.00 ","$13,725.00 ","$10,500.00 ","$12,555.00 ","$13,725.00 ","$13,725.00 ","$13,725.00 ","$5,527.50 ","$9,000.00 ","$4,500.00 ","$13,500.00 ","$11,250.00 ","$12,000.00 ","$12,450.00 "
Hoopeston Regional Hlth Center,9381701,"KIT ASP816VAL MUTATION ANALYSIS, REF",,81273,310,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9381707,"FACTOR V LEIDEN (1691G>A) MUTATION, B",,81241,310,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,9381706,"MTHFR (677C AND 1298C) MUTATIONS, B",,81291,310,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,9381721,"CYTOCHROME P450 2C19 GENOTYPE, REF",,81225,310,"$1,170.00 ","$1,170.00 ",$327.60 ,"$1,070.55 ",$819.00 ,$979.29 ,"$1,070.55 ","$1,070.55 ","$1,070.55 ",$431.15 ,$702.00 ,$351.00 ,"$1,053.00 ",$877.50 ,$936.00 ,$971.10
Hoopeston Regional Hlth Center,9381732,"HBA1/HBA2 GENE ANALYSIS, FULL GENE SUQUENCE",,81259,310,"$2,400.00 ","$2,400.00 ",$672.00 ,"$2,196.00 ","$1,680.00 ","$2,008.80 ","$2,196.00 ","$2,196.00 ","$2,196.00 ",$884.40 ,"$1,440.00 ",$720.00 ,"$2,160.00 ","$1,800.00 ","$1,920.00 ","$1,992.00 "
Hoopeston Regional Hlth Center,9381733,"HEMOGLOBIN, SUBUNIT BETA, DUP/DEL VARIANT(S)",,81363,310,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,9381734,"HEMOGLOBIN, SUNIBIT BETA, FULL GENE SEQUENCE",,81364,310,"$1,300.00 ","$1,300.00 ",$364.00 ,"$1,189.50 ",$910.00 ,"$1,088.10 ","$1,189.50 ","$1,189.50 ","$1,189.50 ",$479.05 ,$780.00 ,$390.00 ,"$1,170.00 ",$975.00 ,"$1,040.00 ","$1,079.00 "
Hoopeston Regional Hlth Center,9381747,"PRADER-WILLI/ANGELMAN SYN, REF",,81331,310,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9381750,"PLATELET ANTIGEN 1 GENOTYPING, REF",,81105,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9381751,"PLATELET ANTIGEN 2 GENOTYPING, REF",,81106,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9381752,"PLATELET ANTIGEN 3 GENOTYPING, REF",,81107,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9381753,"PLATELET ANTIGEN 4 GENOTYPING, REF",,81108,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9381754,"PLATELET ANTIGEN 5 GENOTYPING, REF",,81109,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9381755,"PLATELET ANTIGEN 6 GENOTYPING, REF",,81110,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9381756,"PLATELET ANTIGEN 15 GENOTYPING, REF",,81112,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9381769,"DPYD GENOTYPE, REF",,81232,310,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,9381040,HLA A29 TYPING REF,,81374,310,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9381205,COUNSYL FRAGILE X SYNDROME REF,,81205,310,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,9381250,COUNSYL FRAGILE X SYNDROME REF,,81250,310,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,9381310,NPM1 (NUCLOEPHOSMIN) GENE; EXON 12 VAR,,81310,310,$990.00 ,$990.00 ,$277.20 ,$905.85 ,$693.00 ,$828.63 ,$905.85 ,$905.85 ,$905.85 ,$364.82 ,$594.00 ,$297.00 ,$891.00 ,$742.50 ,$792.00 ,$821.70
Hoopeston Regional Hlth Center,9381092,MATERNIT21 REF,,81479,310,"$1,380.00 ","$1,380.00 ",$386.40 ,"$1,262.70 ",$966.00 ,"$1,155.06 ","$1,262.70 ","$1,262.70 ","$1,262.70 ",$508.53 ,$828.00 ,$414.00 ,"$1,242.00 ","$1,035.00 ","$1,104.00 ","$1,145.40 "
Hoopeston Regional Hlth Center,9381102,FLT3 (ITD) AND TKD MUTATION ASSAY REF,,81245,310,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9381105,MGMT GENE PROMOTER METHYLATION REF,,81287,310,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9381103,HPA MOLECULAR PHENOTYPE REF,,81400,310,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9381115,"HLA B-27 DNA TYPING, REF",,81374,310,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9381116,OVA1 REF,,81503,310,"$3,590.00 ","$3,590.00 ","$1,005.20 ","$3,284.85 ","$2,513.00 ","$3,004.83 ","$3,284.85 ","$3,284.85 ","$3,284.85 ","$1,322.92 ","$2,154.00 ","$1,077.00 ","$3,231.00 ","$2,692.50 ","$2,872.00 ","$2,979.70 "
Hoopeston Regional Hlth Center,9381125,"DECALCIFICATION, REF",,88311,310,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,9381790,"HLA A,B,C HIGH RESOLUTION, REF",,81379,310,"$1,340.00 ","$1,340.00 ",$375.20 ,"$1,226.10 ",$938.00 ,"$1,121.58 ","$1,226.10 ","$1,226.10 ","$1,226.10 ",$493.79 ,$804.00 ,$402.00 ,"$1,206.00 ","$1,005.00 ","$1,072.00 ","$1,112.20 "
Hoopeston Regional Hlth Center,9381791,"COLOVANTAGE, REF",,81327,310,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,9381795,"ALPHA-GLOBIN GENE ANALYSIS, REF",,81269,310,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,9381799,"HEREDITARY COLON CANCER PANEL, REF",,81435,310,"$2,340.00 ","$2,340.00 ",$655.20 ,"$2,141.10 ","$1,638.00 ","$1,958.58 ","$2,141.10 ","$2,141.10 ","$2,141.10 ",$862.29 ,"$1,404.00 ",$702.00 ,"$2,106.00 ","$1,755.00 ","$1,872.00 ","$1,942.20 "
Hoopeston Regional Hlth Center,9381757,HLA B27 ANTIGEN,,81374,310,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9381807,"ONCOTYPE DX BREAST, REF",,81519,310,"$15,490.00 ","$15,490.00 ","$4,337.20 ","$14,173.35 ","$10,843.00 ","$12,965.13 ","$14,173.35 ","$14,173.35 ","$14,173.35 ","$5,708.07 ","$9,294.00 ","$4,647.00 ","$13,941.00 ","$11,617.50 ","$12,392.00 ","$12,856.70 "
Hoopeston Regional Hlth Center,9381315,"PLM/RARA QUANTIATIVE, PCR REF",,81315,310,$830.00 ,$830.00 ,$232.40 ,$759.45 ,$581.00 ,$694.71 ,$759.45 ,$759.45 ,$759.45 ,$305.86 ,$498.00 ,$249.00 ,$747.00 ,$622.50 ,$664.00 ,$688.90
Hoopeston Regional Hlth Center,9381350,"UGT1A1 SEQUENCE, HYPERBILRUBINEMIA, REF",,81350,310,$940.00 ,$940.00 ,$263.20 ,$860.10 ,$658.00 ,$786.78 ,$860.10 ,$860.10 ,$860.10 ,$346.39 ,$564.00 ,$282.00 ,$846.00 ,$705.00 ,$752.00 ,$780.20
Hoopeston Regional Hlth Center,9381847,"CHROMOSOMAL MICROARRAY, AUTOPSY, POC, OR STILLBIRTH, REF",,81229,310,"$4,640.00 ","$4,640.00 ","$1,299.20 ","$4,245.60 ","$3,248.00 ","$3,883.68 ","$4,245.60 ","$4,245.60 ","$4,245.60 ","$1,709.84 ","$2,784.00 ","$1,392.00 ","$4,176.00 ","$3,480.00 ","$3,712.00 ","$3,851.20 "
Hoopeston Regional Hlth Center,9381855,"SMA CARRIER SCREEN, REF",,81401,310,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9381868,"SMA CARRIER SCREEN, REF",,81329,310,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9381883,"JAK2 EXON 12 MUTATION DET, B, REF",,0027U,310,$487.64 ,$487.64 ,$136.54 ,$446.19 ,$341.35 ,$408.15 ,$446.19 ,$446.19 ,$446.19 ,$179.70 ,$292.58 ,$146.29 ,$438.88 ,$365.73 ,$390.11 ,$404.74
Hoopeston Regional Hlth Center,9381885,"MYD88 L265P GENE MUTATION, REF",,81305,310,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,9381921,"ATAXIA, COMPREHENSIVE EVALUATION, REF",,81443,310,"$9,790.00 ","$9,790.00 ","$2,741.20 ","$8,957.85 ","$6,853.00 ","$8,194.23 ","$8,957.85 ","$8,957.85 ","$8,957.85 ","$3,607.62 ","$5,874.00 ","$2,937.00 ","$8,811.00 ","$7,342.50 ","$7,832.00 ","$8,125.70 "
Hoopeston Regional Hlth Center,9381875,MPL EXON 10 MUTATION,,81339,310,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9381874,CALR MUTATION ANALYSIS,,81219,310,$485.00 ,$485.00 ,$135.80 ,$443.78 ,$339.50 ,$405.95 ,$443.78 ,$443.78 ,$443.78 ,$178.72 ,$291.00 ,$145.50 ,$436.50 ,$363.75 ,$388.00 ,$402.55
Hoopeston Regional Hlth Center,9381931,"IDH1 COMMON VARIANTS, REF",,81120,310,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,9381932,"IDH2 COMMON VARIANTS, REF",,81121,310,"$1,180.00 ","$1,180.00 ",$330.40 ,"$1,079.70 ",$826.00 ,$987.66 ,"$1,079.70 ","$1,079.70 ","$1,079.70 ",$434.83 ,$708.00 ,$354.00 ,"$1,062.00 ",$885.00 ,$944.00 ,$979.40
Hoopeston Regional Hlth Center,9381942,"TERT PROMOTER ANALYSIS, REF",,81345,310,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9381945,"TREACHER COLLINS SYNDROME, REF",,81479,310,"$1,380.00 ","$1,380.00 ",$386.40 ,"$1,262.70 ",$966.00 ,"$1,155.06 ","$1,262.70 ","$1,262.70 ","$1,262.70 ",$508.53 ,$828.00 ,$414.00 ,"$1,242.00 ","$1,035.00 ","$1,104.00 ","$1,145.40 "
Hoopeston Regional Hlth Center,9381949,"HYDROCEPHALUS PANEL, REF",,81479,310,"$1,380.00 ","$1,380.00 ",$386.40 ,"$1,262.70 ",$966.00 ,"$1,155.06 ","$1,262.70 ","$1,262.70 ","$1,262.70 ",$508.53 ,$828.00 ,$414.00 ,"$1,242.00 ","$1,035.00 ","$1,104.00 ","$1,145.40 "
Hoopeston Regional Hlth Center,9381950,"EHLERS DANLOS NGS PANEL, REF",,81479,310,"$1,380.00 ","$1,380.00 ",$386.40 ,"$1,262.70 ",$966.00 ,"$1,155.06 ","$1,262.70 ","$1,262.70 ","$1,262.70 ",$508.53 ,$828.00 ,$414.00 ,"$1,242.00 ","$1,035.00 ","$1,104.00 ","$1,145.40 "
Hoopeston Regional Hlth Center,9381956,"LIVER FIBROSIS PANEL, REF",,81596,310,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9381961,"NAIT PANEL, INITIAL SCREENING MATERNAL ONLY, REF",,81111,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9381971,"NEURO ONC EXP PAN, REF",,81455,310,"$11,680.00 ","$11,680.00 ","$3,270.40 ","$10,687.20 ","$8,176.00 ","$9,776.16 ","$10,687.20 ","$10,687.20 ","$10,687.20 ","$4,304.08 ","$7,008.00 ","$3,504.00 ","$10,512.00 ","$8,760.00 ","$9,344.00 ","$9,694.40 "
Hoopeston Regional Hlth Center,9381973,"BCR/ABL, RNA-QUAL, DIAGNOSTIC",,81206,310,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9381974,"BCR/ABL, RNA-QUAL SPECIMEN",,81207,310,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9381975,"BCR/ABL, RNA-QUAL DIAGNOSTIC INTERPRETATION",,81208,310,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,9381972,BCR/ABL 1 P190 QUANT MONITOR,,81207,310,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9381984,"HLA B5801 GENOTYPE, ALLOPURINOL HYPERSENSITIVITY, REF",,81381,310,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9381986,"HUNTINGTON DISEASE, REF",,81177,310,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9381976,"BRAF GENE ANALYSIS, V600 VARIANT(S)",,81210,310,$720.00 ,$720.00 ,$201.60 ,$658.80 ,$504.00 ,$602.64 ,$658.80 ,$658.80 ,$658.80 ,$265.32 ,$432.00 ,$216.00 ,$648.00 ,$540.00 ,$576.00 ,$597.60
Hoopeston Regional Hlth Center,9381977,MSI ANALYSIS,,81301,310,"$1,430.00 ","$1,430.00 ",$400.40 ,"$1,308.45 ","$1,001.00 ","$1,196.91 ","$1,308.45 ","$1,308.45 ","$1,308.45 ",$526.96 ,$858.00 ,$429.00 ,"$1,287.00 ","$1,072.50 ","$1,144.00 ","$1,186.90 "
Hoopeston Regional Hlth Center,9382183,"FOUNDATION ONE CDX, REF",,0037U,310,"$14,000.00 ","$14,000.00 ","$3,920.00 ","$12,810.00 ","$9,800.00 ","$11,718.00 ","$12,810.00 ","$12,810.00 ","$12,810.00 ","$5,159.00 ","$8,400.00 ","$4,200.00 ","$12,600.00 ","$10,500.00 ","$11,200.00 ","$11,620.00 "
Hoopeston Regional Hlth Center,9382184,"MARFAN SYNDROME AND RELATED DISORDERS MULTI GENE PANEL, VARIES, REF",,81410,310,"$2,020.00 ","$2,020.00 ",$565.60 ,"$1,848.30 ","$1,414.00 ","$1,690.74 ","$1,848.30 ","$1,848.30 ","$1,848.30 ",$744.37 ,"$1,212.00 ",$606.00 ,"$1,818.00 ","$1,515.00 ","$1,616.00 ","$1,676.60 "
Hoopeston Regional Hlth Center,9382187,"INHERITEST « 500 PLUE PANEL, REF",,81443,310,"$9,790.00 ","$9,790.00 ","$2,741.20 ","$8,957.85 ","$6,853.00 ","$8,194.23 ","$8,957.85 ","$8,957.85 ","$8,957.85 ","$3,607.62 ","$5,874.00 ","$2,937.00 ","$8,811.00 ","$7,342.50 ","$7,832.00 ","$8,125.70 "
Hoopeston Regional Hlth Center,9382203,"HUNTINGTON DISEASE ANALYSIS, REF",,81271,310,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9382299,"CHROMOSOMAL MICROARRAY, TUMOR, FFPE, REF",,81277,310,"$4,640.00 ","$4,640.00 ","$1,299.20 ","$4,245.60 ","$3,248.00 ","$3,883.68 ","$4,245.60 ","$4,245.60 ","$4,245.60 ","$1,709.84 ","$2,784.00 ","$1,392.00 ","$4,176.00 ","$3,480.00 ","$3,712.00 ","$3,851.20 "
Hoopeston Regional Hlth Center,9382343,"Hc Friedreich Ataxia Repeat Exp Analysis, Ref",,81284,310,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9382352,"HC RESPIRATORY PATHOGEN PANEL, PCR, NP, REF",,0099U,310,"$1,100.00 ","$1,100.00 ",$308.00 ,"$1,006.50 ",$770.00 ,$920.70 ,"$1,006.50 ","$1,006.50 ","$1,006.50 ",$405.35 ,$660.00 ,$330.00 ,$990.00 ,$825.00 ,$880.00 ,$913.00
Hoopeston Regional Hlth Center,9382357,"Hc Congenital Neutropenia Pid Panel, Ref",,81443,310,"$9,790.00 ","$9,790.00 ","$2,741.20 ","$8,957.85 ","$6,853.00 ","$8,194.23 ","$8,957.85 ","$8,957.85 ","$8,957.85 ","$3,607.62 ","$5,874.00 ","$2,937.00 ","$8,811.00 ","$7,342.50 ","$7,832.00 ","$8,125.70 "
Hoopeston Regional Hlth Center,9382369,SARS-COV-2 BY NUCLEIC ACID,,U0003,310,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9382366,"CMT ADV. EVAL, COMP, REF",,81324,310,"$3,030.00 ","$3,030.00 ",$848.40 ,"$2,772.45 ","$2,121.00 ","$2,536.11 ","$2,772.45 ","$2,772.45 ","$2,772.45 ","$1,116.56 ","$1,818.00 ",$909.00 ,"$2,727.00 ","$2,272.50 ","$2,424.00 ","$2,514.90 "
Hoopeston Regional Hlth Center,9382364,"AMYOTROPHIC LATERAL SCLEROSIS ADV. EVAL, REF",,81443,310,"$9,790.00 ","$9,790.00 ","$2,741.20 ","$8,957.85 ","$6,853.00 ","$8,194.23 ","$8,957.85 ","$8,957.85 ","$8,957.85 ","$3,607.62 ","$5,874.00 ","$2,937.00 ","$8,811.00 ","$7,342.50 ","$7,832.00 ","$8,125.70 "
Hoopeston Regional Hlth Center,9382370,"HEMIPLEGIC MIGRAINE SEQ EVAL, REF",,81185,310,"$3,390.00 ","$3,390.00 ",$949.20 ,"$3,101.85 ","$2,373.00 ","$2,837.43 ","$3,101.85 ","$3,101.85 ","$3,101.85 ","$1,249.22 ","$2,034.00 ","$1,017.00 ","$3,051.00 ","$2,542.50 ","$2,712.00 ","$2,813.70 "
Hoopeston Regional Hlth Center,9382416,"SCID PID GENE PANEL, REF",,81443,310,"$9,790.00 ","$9,790.00 ","$2,741.20 ","$8,957.85 ","$6,853.00 ","$8,194.23 ","$8,957.85 ","$8,957.85 ","$8,957.85 ","$3,607.62 ","$5,874.00 ","$2,937.00 ","$8,811.00 ","$7,342.50 ","$7,832.00 ","$8,125.70 "
Hoopeston Regional Hlth Center,9382421,"FIBROTEST-ACTITEST, S REF",,81596,310,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9382477,"Y MICRODELETION, REF",,81403,310,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9382478,"APOLIPOPROTEIN E GENOTYPING, BLOOD, REF",,81401,310,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9382494,"HLA-DR-DQ DisAssoc Typing LowRes, REF",,81376,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9382527,"GI PATHOGEN PANEL, PCR, F",,0097U,310,"$1,450.00 ","$1,450.00 ",$406.00 ,"$1,326.75 ","$1,015.00 ","$1,213.65 ","$1,326.75 ","$1,326.75 ","$1,326.75 ",$534.33 ,$870.00 ,$435.00 ,"$1,305.00 ","$1,087.50 ","$1,160.00 ","$1,203.50 "
Hoopeston Regional Hlth Center,9382554,"JAK-2 V617 MUTATION, B",,81270,310,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,9389006,CYTOGENETICS INTERP/REPORT,,88289,310,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9382714,"SMN1 GENE, FULL GENE ANALYSIS, VARIES, REF",,81336,310,"$1,210.00 ","$1,210.00 ",$338.80 ,"$1,107.15 ",$847.00 ,"$1,012.77 ","$1,107.15 ","$1,107.15 ","$1,107.15 ",$445.89 ,$726.00 ,$363.00 ,"$1,089.00 ",$907.50 ,$968.00 ,"$1,004.30 "
Hoopeston Regional Hlth Center,9382768,"BRCA 1/2 MUTATION ANALYSIS, REF",,81163,310,"$1,870.00 ","$1,870.00 ",$523.60 ,"$1,711.05 ","$1,309.00 ","$1,565.19 ","$1,711.05 ","$1,711.05 ","$1,711.05 ",$689.10 ,"$1,122.00 ",$561.00 ,"$1,683.00 ","$1,402.50 ","$1,496.00 ","$1,552.10 "
Hoopeston Regional Hlth Center,9382770,HP HEREDITARY PHEO/PARAGANGLIOMA PANEL,,81437,310,"$1,760.00 ","$1,760.00 ",$492.80 ,"$1,610.40 ","$1,232.00 ","$1,473.12 ","$1,610.40 ","$1,610.40 ","$1,610.40 ",$648.56 ,"$1,056.00 ",$528.00 ,"$1,584.00 ","$1,320.00 ","$1,408.00 ","$1,460.80 "
Hoopeston Regional Hlth Center,9382798,"HLA TYPING FOR CELIAC DISEASE, REF",,81376,310,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9382797,"HLA TYPING FOR CELIAC DISEASE, REF",,81382,310,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9382786,"BCR-ABL 1 GENE REARRANGEMENT, QUANT, PCR, B [REF]",,81206,310,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9382788,"P190 BCR ABL1, B [REF]",,81207,310,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9382789,"P210 BCR ABL1, B [REF]",,81206,310,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9382800,"UDP-Glucuronosyl Transferase 1A1, Full, REF",,81404,310,"$1,100.00 ","$1,100.00 ",$308.00 ,"$1,006.50 ",$770.00 ,$920.70 ,"$1,006.50 ","$1,006.50 ","$1,006.50 ",$405.35 ,$660.00 ,$330.00 ,$990.00 ,$825.00 ,$880.00 ,$913.00
Hoopeston Regional Hlth Center,9382194,"IGH GENE REARRANGE AMP METH, REF",,81261,310,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,9382193,"IGK REARRANGEABN CLONAL POP, REF",,81264,310,$690.00 ,$690.00 ,$193.20 ,$631.35 ,$483.00 ,$577.53 ,$631.35 ,$631.35 ,$631.35 ,$254.27 ,$414.00 ,$207.00 ,$621.00 ,$517.50 ,$552.00 ,$572.70
Hoopeston Regional Hlth Center,9382857,"GLYCOGEN STORAGE DISEASE GENE PANEL, VAIRES, REF",,81443,310,"$9,790.00 ","$9,790.00 ","$2,741.20 ","$8,957.85 ","$6,853.00 ","$8,194.23 ","$8,957.85 ","$8,957.85 ","$8,957.85 ","$3,607.62 ","$5,874.00 ","$2,937.00 ","$8,811.00 ","$7,342.50 ","$7,832.00 ","$8,125.70 "
Hoopeston Regional Hlth Center,9381873,"MPN-JAK2 V617F W/RFX TO CALR AND MPL, BONE MARROW",,81270,310,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,9383079,"MPL EXON 10 MUTATION DETECTION, V, REF",,81339,310,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9383083,"CELIAC DISEASE HLA DQ2, REF",,81377,310,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,9383084,"CELIAC DISEASE HLA DQ8, REF",,81383,310,$435.00 ,$435.00 ,$121.80 ,$398.03 ,$304.50 ,$364.10 ,$398.03 ,$398.03 ,$398.03 ,$160.30 ,$261.00 ,$130.50 ,$391.50 ,$326.25 ,$348.00 ,$361.05
Hoopeston Regional Hlth Center,9383130,"CMT ADVANCED EVAL - COMP, REF",,81448,310,"$2,340.00 ","$2,340.00 ",$655.20 ,"$2,141.10 ","$1,638.00 ","$1,958.58 ","$2,141.10 ","$2,141.10 ","$2,141.10 ",$862.29 ,"$1,404.00 ",$702.00 ,"$2,106.00 ","$1,755.00 ","$1,872.00 ","$1,942.20 "
Hoopeston Regional Hlth Center,9383132,"SF3B1 MUTATION, REF",,81347,310,$775.00 ,$775.00 ,$217.00 ,$709.13 ,$542.50 ,$648.68 ,$709.13 ,$709.13 ,$709.13 ,$285.59 ,$465.00 ,$232.50 ,$697.50 ,$581.25 ,$620.00 ,$643.25
Hoopeston Regional Hlth Center,9383116,SARS-COV-2/FLU A/ FLU B PCR,,87636,310,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9383168,"HC G6PD FULL GENE SEQUENCING, REF",,81249,310,"$2,400.00 ","$2,400.00 ",$672.00 ,"$2,196.00 ","$1,680.00 ","$2,008.80 ","$2,196.00 ","$2,196.00 ","$2,196.00 ",$884.40 ,"$1,440.00 ",$720.00 ,"$2,160.00 ","$1,800.00 ","$1,920.00 ","$1,992.00 "
Hoopeston Regional Hlth Center,9383176,"PV (JAK2 V617F, EXON 12-15) RELEX, REF",,81270,310,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,9381232,"CPT-GPP-PATHOGEN, PROBE, 12-25 TARGETS",,87507,310,"$1,650.00 ","$1,650.00 ",$462.00 ,"$1,509.75 ","$1,155.00 ","$1,381.05 ","$1,509.75 ","$1,509.75 ","$1,509.75 ",$608.03 ,$990.00 ,$495.00 ,"$1,485.00 ","$1,237.50 ","$1,320.00 ","$1,369.50 "
Hoopeston Regional Hlth Center,Q0111,Wet mounts/ w preparations,,Q0111,310,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9381419,FLOW CYTOM; EA ADDNL MARKER REF,,88185,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9381420,TISSUE CULTURE; SKIN OR SOLID TISSUE REF,,88233,311,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9381421,"MOLEC CYTOGEN; DNA PROBE, EA REF",,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9381422,MOL CYTOGEN; CHROMOSOMAL HYBRID REF,,88273,311,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380400,UNLISTED CYTOGENETIC STUDY REF,,80400,311,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9380224,"FLOW CYTOM, CELL CYCLE OR DNA ANALYSIS REF",,88182,311,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9388001,"CYTOPATH, CONC, SMEAR REF",,88108,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9388108,"CYTOPATHOLOGY, CONCENTRATION T",,88108,311,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9388161,MISC CYTOLOGY,,88108,311,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9388112,CYTO LIQUID-BASED MONO LAYER,,88112,311,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,9388120,"UROVYSION (FISH, BLADDER CANCER)",,88120,311,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9380593,"UROVYSION, BLADDER CANCER REF",,88120,311,$325.00 ,$325.00 ,$91.00 ,$297.38 ,$227.50 ,$272.03 ,$297.38 ,$297.38 ,$297.38 ,$119.76 ,$195.00 ,$97.50 ,$292.50 ,$243.75 ,$260.00 ,$269.75
Hoopeston Regional Hlth Center,9388142,DX CYTO PATH-ML CX /VAG,,88142,311,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9388156,SCREEN CYTO ML CX /VAG PAP,,88142,311,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9388145,TOUCH PREP CYTOLOGY,,88161,311,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9386095,CYTO VAG/CER W/MANU W/PHY SUP,,88175,311,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9386096,"DIAG CYTOL-ML; AUTO, MNL RESCN",,88175,311,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9388177,"CYTOPATHOLOGY, FNA EVAL, IMMD STUDY",,88177,311,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9388012,DNA CONTENT,,88182,311,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9389345,FLOW CYTOMETRY;FIRST MARKR REF,,88184,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9380389,"HGB F, RED CELL DISTRIB, B REF",,88184,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9380607,FLOW CYTOM;FIRST MARKER REF,,88184,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9380610,FLOW CYTOM; FIRST MARKER REF,,88184,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9380739,FLOW CYTOM; FIRST MARKER REF,,88184,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9388184,FLOW CYTOMETRY -FIRST MARKER,,88184,311,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9380608,FLOW CYTOM; EACH ADDTNL REF,,88185,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9380740,FLOW CYTOM; EACH ADDNL MARKER REF,,88185,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9386131,FLOW CYTOMTRY-EA ADNL MARKR RF,,88185,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9386411,FLOW CYTOMTRY-EA ADNL MARKR RF,,88185,311,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9388185,FLOW CYTOMETRY EA ADD MARKER,,88185,311,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9383556,FLOW CYTOMTRY INTERPRETATN REF,,88189,311,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9383865,TISS CULT NON-NEOPL LYMPH REF,,88230,311,$465.00 ,$465.00 ,$130.20 ,$425.48 ,$325.50 ,$389.21 ,$425.48 ,$425.48 ,$425.48 ,$171.35 ,$279.00 ,$139.50 ,$418.50 ,$348.75 ,$372.00 ,$385.95
Hoopeston Regional Hlth Center,9383870,TISSUE CULTURE REF,,88230,311,$465.00 ,$465.00 ,$130.20 ,$425.48 ,$325.50 ,$389.21 ,$425.48 ,$425.48 ,$425.48 ,$171.35 ,$279.00 ,$139.50 ,$418.50 ,$348.75 ,$372.00 ,$385.95
Hoopeston Regional Hlth Center,9384038,TISS CULT NON-NEOPL LYMPH REF,,88230,311,$465.00 ,$465.00 ,$130.20 ,$425.48 ,$325.50 ,$389.21 ,$425.48 ,$425.48 ,$425.48 ,$171.35 ,$279.00 ,$139.50 ,$418.50 ,$348.75 ,$372.00 ,$385.95
Hoopeston Regional Hlth Center,9380432,"CHROMOSOME, TISSUE CULTURE REF",,88233,311,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9388233,TISSUE CULTURE -SKIN BIOPSY RF,,88233,311,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9380398,"CHROMOSOME, AMNIO CULT REF",,88235,311,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,9384441,"CHROMOSOME, AMNIO CULT REF",,88235,311,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,9388235,CHROMO AMNIO FLD CULTURE REF,,88235,311,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,9380402,TISS CULT NEOPL BN MAR/BLD REF,,88237,311,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9388237,TISS CULT NEOPL BN MAR/BLD REF,,88237,311,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9380733,"CRYOPR, FRZ, STORE, EA CELL LINE REF",,88240,311,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9388240,"CRYOPRESERVATION, FREEZE, STORE, EA CELL LINE REF",,88240,311,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9388109,CHROMOSOME ANALYSIS REF,,88262,311,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9388262,CHROM ANALYSIS W/BANDING REF,,88262,311,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9388268,CHROM ANALYSIS W/BANDING REF,,88262,311,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9388270,CHROM 2 CARYOTYPES;BANDING REF,,88262,311,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9388269,"CHROM ANALYSIS, IN SITU REF",,88269,311,$690.00 ,$690.00 ,$193.20 ,$631.35 ,$483.00 ,$577.53 ,$631.35 ,$631.35 ,$631.35 ,$254.27 ,$414.00 ,$207.00 ,$621.00 ,$517.50 ,$552.00 ,$572.70
Hoopeston Regional Hlth Center,9380302,"CYTOGENETICS, DNA PROBE REF",,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380434,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380505,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380533,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380731,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380753,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380761,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380774,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380866,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380868,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380870,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380872,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380874,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380876,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380878,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380880,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380882,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380884,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380886,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380888,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380890,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380892,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380894,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380896,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380898,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380900,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380902,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380904,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380906,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9382268,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9382795,MOL CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9383596,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9388271,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9382802,MOL CYTOGEN; HYBRIDIZ REF,,88273,311,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9383629,MOLEC CYTOGEN; HYBRIDIZATN REF,,88273,311,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9388273,MOLEC CYTOGEN; HYBRIDIZATN REF,,88273,311,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9380303,"CYTOGENETICS, 100-300 REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380435,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380506,MOL CYT INTPH ISH 100-300 CELLS REF,,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380534,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380732,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380754,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380762,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380775,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380867,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380869,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380871,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380873,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380875,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380877,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380879,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380881,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380883,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380885,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380887,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380889,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380891,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380893,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380895,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380897,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380899,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380901,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380903,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380905,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380907,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9383597,MOL CYT INTRPH IS HYBRID REF,,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9388275,MOL CYT INTRPH IS HYBRID REF,,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380399,"CHROM ANAL, ADDNL KARYOTYPE REF",,88280,311,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9388280,CHROMO ANA AMNIO FLUID REF,,88280,311,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9380304,CYTO/MOLECULAR REPORT REF,,88291,311,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9388291,CYTO/MOLE GENE INTER REF,,88291,311,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9389007,CYTO/MOLE GENETICS INTER REF,,88291,311,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9380403,UNLISETD CYTOGENETIC STUDY REF,,88299,311,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9380433,UNLISETD CYTOGENETIC STUDY REF,,88299,311,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9380258,SOLID TISSUE BIOPSY REF,,88233,311,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9380259,CRYOPRESERVATION REF,,88240,311,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380260,AMNIOTIC FL CULT/GENETIC REF,,88235,311,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,9380261,CRYOPRESERVATION REF,,88240,311,$52.00 ,$52.00 ,$14.56 ,$47.58 ,$36.40 ,$43.52 ,$47.58 ,$47.58 ,$47.58 ,$19.16 ,$31.20 ,$15.60 ,$46.80 ,$39.00 ,$41.60 ,$43.16
Hoopeston Regional Hlth Center,9380657,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380658,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380660,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380662,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380664,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380666,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380668,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380670,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380672,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380674,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380676,"MOL CYT INTPH ISH,100-300 CELLS REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9380659,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380661,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380663,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380665,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380667,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380669,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380671,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380673,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9380675,MOLEC CYTOGEN; DNA PROBE REF,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9381659,"ONCO CHROMOSOME ANALYSIS, REF",,88237,311,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9381037,"CHROMOSOME ANALY, COUNT 5 CELLS REF",,88261,311,"$1,060.00 ","$1,060.00 ",$296.80 ,$969.90 ,$742.00 ,$887.22 ,$969.90 ,$969.90 ,$969.90 ,$390.61 ,$636.00 ,$318.00 ,$954.00 ,$795.00 ,$848.00 ,$879.80
Hoopeston Regional Hlth Center,9381038,"CHROMOSOME ANALY, ADDT CELLS COUNTED REF",,88285,311,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9381078,MOLEC CYTOGEN; HYBRIDIZATN REF,,88273,311,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9381091,CYTOGENETIC STUDY REF,,88299,311,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9381113,LEUKEMIA LYMPHOMA CD45,,88184,311,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,9381904,"Hc Leuk/lymph Phenotype, Ref",,88189,311,$356.00 ,$356.00 ,$99.68 ,$325.74 ,$249.20 ,$297.97 ,$325.74 ,$325.74 ,$325.74 ,$131.19 ,$213.60 ,$106.80 ,$320.40 ,$267.00 ,$284.80 ,$295.48
Hoopeston Regional Hlth Center,9381930,"IGP, COBAS HPV 18, REF",,88175,311,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9381964,"BAND 3 FLUORESCENCE ST, REF",,88184,311,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9382560,"CYTOGENETICS, 100-300, REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9382561,"CYTOGENETICS DNA PROBE, REF",,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9382567,"FISH, CML/ALL, BCR/ABL TRANSLOCATION 9,22",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9382566,CPT-MOLECULAR CYTOGENETICS PROBE,,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9382596,"CPT-CYTOGENETICS, 100-300, REF",,88275,311,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9382597,"CPT-CYTOGENETICS DNA PROBE, REF",,88271,311,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9388312,SPECIAL STAINS -GROUP I,,88312,312,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9385665,SPECIAL STAINS GROUP I REF,,88312,312,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9388313,SPECIAL STAINS -GROUP II,,88313,312,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9385667,SPECIAL STAINS GROUP II REF,,88313,312,$73.00 ,$73.00 ,$20.44 ,$66.80 ,$51.10 ,$61.10 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.80 ,$21.90 ,$65.70 ,$54.75 ,$58.40 ,$60.59
Hoopeston Regional Hlth Center,9388413,SPECIAL STAINS -GROUP II,,88313,312,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9388323,TECHNICL PREP-PATH CONSULT REF,,88323,312,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9388423,MICRO SLIDE PREPR FOR CONSULT,,88323,312,$375.00 ,$375.00 ,$105.00 ,$343.13 ,$262.50 ,$313.88 ,$343.13 ,$343.13 ,$343.13 ,$138.19 ,$225.00 ,$112.50 ,$337.50 ,$281.25 ,$300.00 ,$311.25
Hoopeston Regional Hlth Center,9388334,INTRAOPERATIVE PATHOLOGY EXAM,,88334,312,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9388442,IMMUNOCHEM ANTIBODY,,88342,312,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9380476,MLH1 IHC REF,,88342,312,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9380477,MSH2 IHC REF,,88342,312,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9380478,MSH6 IHC REF,,88342,312,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9380479,PMS2 IHC REF,,88342,312,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9389350,IMMUNOCHEM ANTIBODY REF,,88342,312,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9388446,IMMUNOFL STDY DIRECT EA AB,,88346,312,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9388346,IMMUNOFL STDY DIRECT EA AB REF,,88346,312,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9388358,MORPHOMETRIC ANALYSIS-TUMR REF,,88358,312,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9386427,TUMOR IMMUNOCHEM MANUAL,,88360,312,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,9385585,TUMOR IMMUNOCHEM MANUAL REF,,88360,312,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9389210,TUMR IMMUNOHISTOCHM W/CMPTR RF,,88361,312,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9388361,TUMOR IMM HISTOCHEM W/COMPUTER,,88361,312,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9388367,MORPHOMETRIC ANALYSIS -EACH,,88367,312,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9388368,MORPHOMETRIC ANALYSIS -EACH,,88368,312,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9389256,MORPHOMETRIC ANALYSIS-EACH REF,,88368,312,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9388380,MICRODISSECTION LASER CAPTURE REF,,88380,312,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,9388381,MICRODISSECTION MANUAL,,88381,312,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,9380237,MORPH ANALYSIS IN SITU HYBRIDZTN EA PROBE CMPTR ASST,,88367,312,"$1,230.00 ","$1,230.00 ",$344.40 ,"$1,125.45 ",$861.00 ,"$1,029.51 ","$1,125.45 ","$1,125.45 ","$1,125.45 ",$453.26 ,$738.00 ,$369.00 ,"$1,107.00 ",$922.50 ,$984.00 ,"$1,020.90 "
Hoopeston Regional Hlth Center,9380238,MORPH ANALYSIS IN SITU HYBRIDZTN EA PROBE MANUAL,,88368,312,"$1,090.00 ","$1,090.00 ",$305.20 ,$997.35 ,$763.00 ,$912.33 ,$997.35 ,$997.35 ,$997.35 ,$401.67 ,$654.00 ,$327.00 ,$981.00 ,$817.50 ,$872.00 ,$904.70
Hoopeston Regional Hlth Center,9381522,ANTI-ENDOMYSIAL (EMA) IGA AB (CELIAC-PROMETH) REF,,88346,312,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381523,ANTI-ENDOMYSIAL (EMA) IGA AB (CELIAC-PROMETH) REF,,88346,312,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381526,IMMFL ST; SINGLE AG PER SPEC (CROHN-PROM) REF,,88346,312,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381528,IMMFL ST; SINGLE AB PER SPEC (SGI-PROM) REF,,88346,312,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9381617,MORPHOMETRIC ANALYSIS REF,,88356,312,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,9381715,"BILLIARY TRACT MALIGNANCY, FISH, REF",,88377,312,$545.00 ,$545.00 ,$152.60 ,$498.68 ,$381.50 ,$456.17 ,$498.68 ,$498.68 ,$498.68 ,$200.83 ,$327.00 ,$163.50 ,$490.50 ,$408.75 ,$436.00 ,$452.35
Hoopeston Regional Hlth Center,9381234,IHC EA ADDTL SINGLE AB STAIN PROCEDURE REF,,88341,312,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9381236,IHC EA MULTIPLEX AB STAIN PROCEDURE REF,,88344,312,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9381237,IN SITU HYBRID EA ADDTL SINGLE PROBE REF,,88364,312,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9381238,IN SITU HYBRID EA MULTIPLEX PROBE STAIN REF,,88366,312,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9381239,"MORPH ANALY, IN SITU HYBRID, COMP ASST, EA ADDTL STAIN REF",,88373,312,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9381240,"MORPH ANALY, IN SITU HYBRID, COMP ASST, EA MULTIPLEX REF",,88374,312,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9381245,"MORPH ANALY, IN SITU HYBRID, MANUAL, EA ADDTL SINGLE PROBE REF",,88369,312,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9381246,"MORPH ANALY, IN SITU HYBRID, MANUAL, EA MULTIPLEX REF",,88377,312,$545.00 ,$545.00 ,$152.60 ,$498.68 ,$381.50 ,$456.17 ,$498.68 ,$498.68 ,$498.68 ,$200.83 ,$327.00 ,$163.50 ,$490.50 ,$408.75 ,$436.00 ,$452.35
Hoopeston Regional Hlth Center,9388341,IHC EA ADDTL SINGLE AB STAIN PROCEDURE,,88341,312,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9388344,IHC EA MULTIPLEX AB STAIN PROCEDURE,,88344,312,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9388364,IN SITU HYBRID EA ADDTL SINGLE PROBE,,88364,312,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,9388366,IN SITU HYBRID EA MULTIPLEX PROBE STAIN,,88366,312,"$1,070.00 ","$1,070.00 ",$299.60 ,$979.05 ,$749.00 ,$895.59 ,$979.05 ,$979.05 ,$979.05 ,$394.30 ,$642.00 ,$321.00 ,$963.00 ,$802.50 ,$856.00 ,$888.10
Hoopeston Regional Hlth Center,9388373,"MORPH ANALY, IN SITU HYBRID, COMP ASST, EA ADDTL STAIN",,88373,312,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9388374,"MORPH ANALY, IN SITU HYBRID, COMP ASST, EA MULTIPLEX",,88374,312,"$1,970.00 ","$1,970.00 ",$551.60 ,"$1,802.55 ","$1,379.00 ","$1,648.89 ","$1,802.55 ","$1,802.55 ","$1,802.55 ",$725.95 ,"$1,182.00 ",$591.00 ,"$1,773.00 ","$1,477.50 ","$1,576.00 ","$1,635.10 "
Hoopeston Regional Hlth Center,9388369,"MORPH ANALY, IN SITU HYBRID, MANUAL, EA ADDTL SINGLE PROBE",,88369,312,$620.00 ,$620.00 ,$173.60 ,$567.30 ,$434.00 ,$518.94 ,$567.30 ,$567.30 ,$567.30 ,$228.47 ,$372.00 ,$186.00 ,$558.00 ,$465.00 ,$496.00 ,$514.60
Hoopeston Regional Hlth Center,9388377,"MORPH ANALY, IN SITU HYBRID, MANUAL, EA MULTIPLEX",,88377,312,"$1,830.00 ","$1,830.00 ",$512.40 ,"$1,674.45 ","$1,281.00 ","$1,531.71 ","$1,674.45 ","$1,674.45 ","$1,674.45 ",$674.36 ,"$1,098.00 ",$549.00 ,"$1,647.00 ","$1,372.50 ","$1,464.00 ","$1,518.90 "
Hoopeston Regional Hlth Center,9381196,"PROSTATE NEEDLE BX SPECIMENS, ANY METHOD",,G0416,314,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9413660,TOE(S) AP/LAT ONLY,,73660,320,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9417074,METASTATIC BONE SURVEY,,77074,320,"$1,070.00 ","$1,070.00 ",$299.60 ,$979.05 ,$749.00 ,$895.59 ,$979.05 ,$979.05 ,$979.05 ,$394.30 ,$642.00 ,$321.00 ,$963.00 ,$802.50 ,$856.00 ,$888.10
Hoopeston Regional Hlth Center,9417077,HANDS & WRISTS PA BILATERAL,,77077,320,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9423030,SHOULDER 3 VW,,73030,320,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9427074,LONG BONE SURVEY,,77074,320,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,9427077,ARTHRITIS SURVEY,,77077,320,"$1,070.00 ","$1,070.00 ",$299.60 ,$979.05 ,$749.00 ,$895.59 ,$979.05 ,$979.05 ,$979.05 ,$394.30 ,$642.00 ,$321.00 ,$963.00 ,$802.50 ,$856.00 ,$888.10
Hoopeston Regional Hlth Center,9451600,INJECTION FOR CYSTOGRAM,,51600,320,$720.00 ,$720.00 ,$201.60 ,$658.80 ,$504.00 ,$602.64 ,$658.80 ,$658.80 ,$658.80 ,$265.32 ,$432.00 ,$216.00 ,$648.00 ,$540.00 ,$576.00 ,$597.60
Hoopeston Regional Hlth Center,9470030,EYE FOR FOREIGN BODY,,70030,320,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9470110,MANDIBLE BIL-MIN 4V EA SIDE,,70110,320,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,9470130,MASTOIDS BIL-MIN 3V PER SIDE,,70130,320,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9470134,INT AUDITORY MEATI,,70134,320,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,9470140,ZYGOMATIC ARCHES <3V,,70140,320,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,9470150,FACIAL BONES MIN 3V,,70150,320,$375.00 ,$375.00 ,$105.00 ,$343.13 ,$262.50 ,$313.88 ,$343.13 ,$343.13 ,$343.13 ,$138.19 ,$225.00 ,$112.50 ,$337.50 ,$281.25 ,$300.00 ,$311.25
Hoopeston Regional Hlth Center,9470160,NASAL BONES MIN 3V,,70160,320,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9470190,OPTIC FORAMINA BILAT,,70190,320,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9470200,ORBITS MIN 4V,,70200,320,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9470210,SINUSES LTD <3V,,70210,320,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,9470220,SINUSES PARANASAL MIN 3V,,70220,320,$375.00 ,$375.00 ,$105.00 ,$343.13 ,$262.50 ,$313.88 ,$343.13 ,$343.13 ,$343.13 ,$138.19 ,$225.00 ,$112.50 ,$337.50 ,$281.25 ,$300.00 ,$311.25
Hoopeston Regional Hlth Center,9470250,SKULL LIMITED <4V,,70250,320,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9470260,SKULL MIN 4VW,,70260,320,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9470330,TM JOINTS BILAT,,70330,320,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,9470360,NECK-SOFT TISSUE,,70360,320,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9471100,RIBS UNI LIMITED 2V,,71100,320,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9471101,RIBS UNI W/PA CXR MIN 3V,,71101,320,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9471111,RIBS BIL W/PA CXR-MIN 4V,,71111,320,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9471120,STERNUM-MIN 2V,,71120,320,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9471130,STERNOCLAV JTS BIL-MIN 3V,,71130,320,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9472040,CERVICAL SP 2 VW,,72040,320,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9472050,CERVICAL W/OBLS-MIN 4V,,72050,320,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9472052,CERVICAL MIN 7VWS COMPLETE W/ FLEXION/EX,,72052,320,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,9472070,THORACIC SPINE 2 VW,,72070,320,$410.00 ,$410.00 ,$114.80 ,$375.15 ,$287.00 ,$343.17 ,$375.15 ,$375.15 ,$375.15 ,$151.09 ,$246.00 ,$123.00 ,$369.00 ,$307.50 ,$328.00 ,$340.30
Hoopeston Regional Hlth Center,9472074,THORACIC SPINE W/OBL-MIN 4V,,72074,320,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9472080,THORALUMBAR SPINE-2V,,72080,320,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,9472100,LUMBAR SPINE 2 VW,,72100,320,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9472110,LUMBOSACRAL WITH OBL-MIN 4V,,72110,320,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,9472114,LUMBAR SPINE W/BEND,,72114,320,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9472120,LUMBAR BENDING ONLY-MIN 4V,,72120,320,$475.00 ,$475.00 ,$133.00 ,$434.63 ,$332.50 ,$397.58 ,$434.63 ,$434.63 ,$434.63 ,$175.04 ,$285.00 ,$142.50 ,$427.50 ,$356.25 ,$380.00 ,$394.25
Hoopeston Regional Hlth Center,9472170,PELVIS 1-2VWS,,72170,320,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,9472190,PELVIS 3 VW,,72190,320,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9472202,SACROILIACS JNTS-MIN 3V,,72202,320,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9472220,SACRUM AND COCCYX-MIN 2V,,72220,320,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,9473000,CLAVICLE,,73000,320,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9473010,SCAPULA,,73010,320,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9473020,SHOULDER 1 VW,,73020,320,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9473030,SHOULDER 2 VW,,73030,320,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9473050,AC JOINTS BILATERAL,,73050,320,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9473060,HUMERUS-MIN 2V,,73060,320,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9473070,ELBOW LIMITED 2V,,73070,320,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,9473080,ELBOW 3-4 VW,,73080,320,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9473090,FOREARM 2V,,73090,320,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9473092,UPPER EXT INF 2V,,73092,320,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9473100,WRIST LIMITED 2V,,73100,320,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9473110,WRIST 3 VW,,73110,320,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9473120,HAND 2 VW,,73120,320,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9473130,HAND MIN 3V,,73130,320,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9473140,XRAY FINGER(S) MIN 2 VIEWS,,73140,320,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9473560,KNEE 1-2 VW,,73560,320,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9473562,KNEE 3 VW,,73562,320,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9473564,KNEE 4+ VW,,73564,320,$650.00 ,$650.00 ,$182.00 ,$594.75 ,$455.00 ,$544.05 ,$594.75 ,$594.75 ,$594.75 ,$239.53 ,$390.00 ,$195.00 ,$585.00 ,$487.50 ,$520.00 ,$539.50
Hoopeston Regional Hlth Center,9473565,KNEE/S AP STANDING BILATERAL,,73565,320,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9473590,LOWER LEG 2V,,73590,320,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9473592,LOWER EXT INFANT 2V,,73592,320,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9473600,ANKLE LIMITED 2V,,73600,320,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9473610,ANKLE 3-4 VW,,73610,320,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9473620,FOOT LIMITED 2V,,73620,320,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9473630,FOOT 3 VW,,73630,320,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9473650,OS CALCIS/HEEL MIN 2V,,73650,320,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9473660,TOE(S) COMPLETE,,73660,320,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9474022,ABDOMEN OBSTR SERIES-W 1V CXR,,74022,320,$890.00 ,$890.00 ,$249.20 ,$814.35 ,$623.00 ,$744.93 ,$814.35 ,$814.35 ,$814.35 ,$327.97 ,$534.00 ,$267.00 ,$801.00 ,$667.50 ,$712.00 ,$738.70
Hoopeston Regional Hlth Center,9474250,SMALL BOWEL SERIES,,74250,320,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,9474300,CHOLANGIOGRAM OPER,,74300,320,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,9474400,IV PYELOGRAM,,74400,320,"$1,050.00 ","$1,050.00 ",$294.00 ,$960.75 ,$735.00 ,$878.85 ,$960.75 ,$960.75 ,$960.75 ,$386.93 ,$630.00 ,$315.00 ,$945.00 ,$787.50 ,$840.00 ,$871.50
Hoopeston Regional Hlth Center,9474420,RETROGRADE PYELOGRAM,,74420,320,$840.00 ,$840.00 ,$235.20 ,$768.60 ,$588.00 ,$703.08 ,$768.60 ,$768.60 ,$768.60 ,$309.54 ,$504.00 ,$252.00 ,$756.00 ,$630.00 ,$672.00 ,$697.20
Hoopeston Regional Hlth Center,9474430,CYSTOGRAM,,74430,320,$670.00 ,$670.00 ,$187.60 ,$613.05 ,$469.00 ,$560.79 ,$613.05 ,$613.05 ,$613.05 ,$246.90 ,$402.00 ,$201.00 ,$603.00 ,$502.50 ,$536.00 ,$556.10
Hoopeston Regional Hlth Center,9476000,C-ARM FLUORO < 1 HOUR,,76000,320,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,9476001,ORTHOPEDIC C-ARM CASE NON-HIP,,76001,320,$920.00 ,$920.00 ,$257.60 ,$841.80 ,$644.00 ,$770.04 ,$841.80 ,$841.80 ,$841.80 ,$339.02 ,$552.00 ,$276.00 ,$828.00 ,$690.00 ,$736.00 ,$763.60
Hoopeston Regional Hlth Center,9476010,"NOSE TO RECTUM,FB SINGLE VIEW",,76010,320,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9477074,SKELETAL SURVEY,,77074,320,"$1,060.00 ","$1,060.00 ",$296.80 ,$969.90 ,$742.00 ,$887.22 ,$969.90 ,$969.90 ,$969.90 ,$390.61 ,$636.00 ,$318.00 ,$954.00 ,$795.00 ,$848.00 ,$879.80
Hoopeston Regional Hlth Center,9477076,"GENTIC SKELETAL SURVEY, INFANT",,77076,320,"$1,100.00 ","$1,100.00 ",$308.00 ,"$1,006.50 ",$770.00 ,$920.70 ,"$1,006.50 ","$1,006.50 ","$1,006.50 ",$405.35 ,$660.00 ,$330.00 ,$990.00 ,$825.00 ,$880.00 ,$913.00
Hoopeston Regional Hlth Center,9477077,JOINT SURVEY SINGLE VIEW 2 OR MORE JOINT,,77077,320,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9477080,BONE DENSITY (DEXA) AXIAL SKELETON,,77080,320,$720.00 ,$720.00 ,$201.60 ,$658.80 ,$504.00 ,$602.64 ,$658.80 ,$658.80 ,$658.80 ,$265.32 ,$432.00 ,$216.00 ,$648.00 ,$540.00 ,$576.00 ,$597.60
Hoopeston Regional Hlth Center,9476098,MM BREAST SURG SPECMN,,76098,320,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9472020,EXAM SPINE SINGEL VIEW,,72020,320,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9472072,THORACIC SPINE 3 VW,,72072,320,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9470328,TMJ XRAYS -UNILATERAL,,70328,320,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9472200,SACROILIAC JOINTS XRAYS <3 VWS,,72200,320,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9477081,"BONE DENSITY (DEXA), APPENDICULAR SKELETON",,77081,320,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9472081,RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 1 VW,,72081,320,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,9472082,RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 2/3 VW,,72082,320,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9472083,RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 4/5 VW,,72083,320,$650.00 ,$650.00 ,$182.00 ,$594.75 ,$455.00 ,$544.05 ,$594.75 ,$594.75 ,$594.75 ,$239.53 ,$390.00 ,$195.00 ,$585.00 ,$487.50 ,$520.00 ,$539.50
Hoopeston Regional Hlth Center,9472084,RADEX ENTIR THRC LMBR CRV SAC SPI W/SKULL 6/> VW,,72084,320,$760.00 ,$760.00 ,$212.80 ,$695.40 ,$532.00 ,$636.12 ,$695.40 ,$695.40 ,$695.40 ,$280.06 ,$456.00 ,$228.00 ,$684.00 ,$570.00 ,$608.00 ,$630.80
Hoopeston Regional Hlth Center,9473501,RADEX HIP UNILATERAL WITH PELVIS 1 VIEW,,73501,320,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9473502,RADEX HIP UNILATERAL WITH PELVIS 2-3 VIEWS,,73502,320,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9473503,RADEX HIP UNILATERAL WITH PELVIS MINIMUM 4 VIEWS,,73503,320,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9473521,RADEX HIP BILATERAL WITH PELVIS 2 VIEWS,,73521,320,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9473522,RADEX HIP BILATERAL WITH PELVIS 3-4 VIEWS,,73522,320,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9473523,RADEX HIP BILATERAL WITH PELVIS MINIMUM 5 VIEWS,,73523,320,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,9473551,RADIOLOGIC EXAMINATION FEMUR 1 VIEW,,73551,320,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9473552,RADIOLOGIC EXAMINATION FEMUR MINIMUM 2 VIEWS,,73552,320,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9474240,UPPER GI (STOMACH) XRAYS,,74240,320,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9474270,RAD EXAM COLON CONTRAST ENEMA,,74270,320,$800.00 ,$800.00 ,$224.00 ,$732.00 ,$560.00 ,$669.60 ,$732.00 ,$732.00 ,$732.00 ,$294.80 ,$480.00 ,$240.00 ,$720.00 ,$600.00 ,$640.00 ,$664.00
Hoopeston Regional Hlth Center,9471110,RIB XRAYS BILATERAL 3 VIEWS,,71110,320,$61.00 ,$61.00 ,$17.08 ,$55.82 ,$42.70 ,$51.06 ,$55.82 ,$55.82 ,$55.82 ,$22.48 ,$36.60 ,$18.30 ,$54.90 ,$45.75 ,$48.80 ,$50.63
Hoopeston Regional Hlth Center,9477072,BONE AGE STUDIES,,77072,320,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9471045,RADIOLOGIC EXAM CHEST SINGLE VIEW,,71045,320,$400.00 ,$400.00 ,$112.00 ,$366.00 ,$280.00 ,$334.80 ,$366.00 ,$366.00 ,$366.00 ,$147.40 ,$240.00 ,$120.00 ,$360.00 ,$300.00 ,$320.00 ,$332.00
Hoopeston Regional Hlth Center,9471046,RADIOLOGIC EXAM CHEST 2 VIEWS,,71046,320,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9471047,RADIOLOGIC EXAM CHEST 3 VIEWS,,71047,320,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9471048,RADIOLOGIC EXAM CHEST 4+ VIEWS,,71048,320,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,9474018,RADIOLOGIC EXAM ABDOMEN 1 VIEW,,74018,320,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9474019,RADIOLOGIC EXAM ABDOMEN 2 VIEWS,,74019,320,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,9474021,RADIOLOGIC EXAM ABDOMEN 3+ VIEWS,,74021,320,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,9477001,FLUORO GDNC CNTRL VN ACC DVC,,77001,320,$375.00 ,$375.00 ,$105.00 ,$343.13 ,$262.50 ,$313.88 ,$343.13 ,$343.13 ,$343.13 ,$138.19 ,$225.00 ,$112.50 ,$337.50 ,$281.25 ,$300.00 ,$311.25
Hoopeston Regional Hlth Center,9477075,OSSEOUS SURVEY COMPLETE,,77075,320,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9470100,MANDIBLE XRAYS <4 VIEWS,,70100,320,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,9474221,RADIOLOGIC EXAM ESOPHAGUS DOUBLE CONTRAST STUDY,,74221,320,"$1,010.00 ","$1,010.00 ",$282.80 ,$924.15 ,$707.00 ,$845.37 ,$924.15 ,$924.15 ,$924.15 ,$372.19 ,$606.00 ,$303.00 ,$909.00 ,$757.50 ,$808.00 ,$838.30
Hoopeston Regional Hlth Center,9474248,RADIOLOGIC SMALL INTESTINE FOLLOW-THROUGH STUDY,,74248,320,"$1,700.00 ","$1,700.00 ",$476.00 ,"$1,555.50 ","$1,190.00 ","$1,422.90 ","$1,555.50 ","$1,555.50 ","$1,555.50 ",$626.45 ,"$1,020.00 ",$510.00 ,"$1,530.00 ","$1,275.00 ","$1,360.00 ","$1,411.00 "
Hoopeston Regional Hlth Center,9476145,MEDICAL PHYSICS DOSE EVAL RADIATION EXPOS W/RPRT,,76145,320,$750.00 ,$750.00 ,$210.00 ,$686.25 ,$525.00 ,$627.75 ,$686.25 ,$686.25 ,$686.25 ,$276.38 ,$450.00 ,$225.00 ,$675.00 ,$562.50 ,$600.00 ,$622.50
Hoopeston Regional Hlth Center,96401,"CHEMOTHER,NON-HORMONE ANTI-NEOPL, SUB-Q/IM",,96401,331,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,96402,CHEMOTHER HORMON ANTINEOPL SUB-Q/IM,,96402,331,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9896413,CHEMO IV INFUSION -UP TO 1HR,,96413,335,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,9896415,CHEMO IV INFUSION -EA ADNL HR,,96415,335,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9096413,CHEMO IV INFUSION -UP TO 1HR,,96413,335,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,9096415,CHEMO IV INFUSION -EA ADNL HR,,96415,335,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9478013,THYROID IMAGING W/BLOOD FLOW,,78013,340,"$1,100.00 ","$1,100.00 ",$308.00 ,"$1,006.50 ",$770.00 ,$920.70 ,"$1,006.50 ","$1,006.50 ","$1,006.50 ",$405.35 ,$660.00 ,$330.00 ,$990.00 ,$825.00 ,$880.00 ,$913.00
Hoopeston Regional Hlth Center,9478014,THYROID IMAGING W/BLOOD FLOW,,78014,340,"$1,280.00 ","$1,280.00 ",$358.40 ,"$1,171.20 ",$896.00 ,"$1,071.36 ","$1,171.20 ","$1,171.20 ","$1,171.20 ",$471.68 ,$768.00 ,$384.00 ,"$1,152.00 ",$960.00 ,"$1,024.00 ","$1,062.40 "
Hoopeston Regional Hlth Center,9478429,MYOCRD IMG PET METAB EVAL SINGLE STUDY CNCRNT CT,,78429,340,"$4,550.00 ","$4,550.00 ","$1,274.00 ","$4,163.25 ","$3,185.00 ","$3,808.35 ","$4,163.25 ","$4,163.25 ","$4,163.25 ","$1,676.68 ","$2,730.00 ","$1,365.00 ","$4,095.00 ","$3,412.50 ","$3,640.00 ","$3,776.50 "
Hoopeston Regional Hlth Center,9478430,MYOCRD IMG PET PRFUJ 1STD REST/STRESS CNCRNT CT,,78430,340,"$4,550.00 ","$4,550.00 ","$1,274.00 ","$4,163.25 ","$3,185.00 ","$3,808.35 ","$4,163.25 ","$4,163.25 ","$4,163.25 ","$1,676.68 ","$2,730.00 ","$1,365.00 ","$4,095.00 ","$3,412.50 ","$3,640.00 ","$3,776.50 "
Hoopeston Regional Hlth Center,9478431,MYOCRD IMG PET PRFUJ MLT STD RST&STRS CNCRNT CT,,78431,340,"$7,090.00 ","$7,090.00 ","$1,985.20 ","$6,487.35 ","$4,963.00 ","$5,934.33 ","$6,487.35 ","$6,487.35 ","$6,487.35 ","$2,612.67 ","$4,254.00 ","$2,127.00 ","$6,381.00 ","$5,317.50 ","$5,672.00 ","$5,884.70 "
Hoopeston Regional Hlth Center,9478432,MYOCRD IMG PET PRFUJ W/METAB DUAL RADIOTRACER,,78432,340,"$8,650.00 ","$8,650.00 ","$2,422.00 ","$7,914.75 ","$6,055.00 ","$7,240.05 ","$7,914.75 ","$7,914.75 ","$7,914.75 ","$3,187.53 ","$5,190.00 ","$2,595.00 ","$7,785.00 ","$6,487.50 ","$6,920.00 ","$7,179.50 "
Hoopeston Regional Hlth Center,9478433,MYOCRD IMG PET PRFUJ W/METAB 2RTRACER CNCRNT CT,,78433,340,"$8,650.00 ","$8,650.00 ","$2,422.00 ","$7,914.75 ","$6,055.00 ","$7,240.05 ","$7,914.75 ","$7,914.75 ","$7,914.75 ","$3,187.53 ","$5,190.00 ","$2,595.00 ","$7,785.00 ","$6,487.50 ","$6,920.00 ","$7,179.50 "
Hoopeston Regional Hlth Center,9478434,AQMBF PET REST AND PHARMACOLOGIC STRESS,,78434,340,"$2,560.00 ","$2,560.00 ",$716.80 ,"$2,342.40 ","$1,792.00 ","$2,142.72 ","$2,342.40 ","$2,342.40 ","$2,342.40 ",$943.36 ,"$1,536.00 ",$768.00 ,"$2,304.00 ","$1,920.00 ","$2,048.00 ","$2,124.80 "
Hoopeston Regional Hlth Center,9478830,RP LOCLZJ TUM SPECT W/CT 1 AREA 1 DAY IMAGING,,78830,340,"$1,960.00 ","$1,960.00 ",$548.80 ,"$1,793.40 ","$1,372.00 ","$1,640.52 ","$1,793.40 ","$1,793.40 ","$1,793.40 ",$722.26 ,"$1,176.00 ",$588.00 ,"$1,764.00 ","$1,470.00 ","$1,568.00 ","$1,626.80 "
Hoopeston Regional Hlth Center,9478831,RP LOCLZJ TUM SPECT 2 AREA 1D IMG/1 AREA IMG>2+D,,78831,340,"$2,360.00 ","$2,360.00 ",$660.80 ,"$2,159.40 ","$1,652.00 ","$1,975.32 ","$2,159.40 ","$2,159.40 ","$2,159.40 ",$869.66 ,"$1,416.00 ",$708.00 ,"$2,124.00 ","$1,770.00 ","$1,888.00 ","$1,958.80 "
Hoopeston Regional Hlth Center,9478832,RP LOCLZJ TUM SPECT CT 2AREA 1D IMG/1 AR IMG>2+D,,78832,340,"$2,510.00 ","$2,510.00 ",$702.80 ,"$2,296.65 ","$1,757.00 ","$2,100.87 ","$2,296.65 ","$2,296.65 ","$2,296.65 ",$924.94 ,"$1,506.00 ",$753.00 ,"$2,259.00 ","$1,882.50 ","$2,008.00 ","$2,083.30 "
Hoopeston Regional Hlth Center,9478835,RADIOPHARMACEUTICAL QUANTIFICATION MEAS 1 AREA,,78835,340,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9478305,BONE/JOINT IMAGING -MULT AREAS,,78305,341,"$1,020.00 ","$1,020.00 ",$285.60 ,$933.30 ,$714.00 ,$853.74 ,$933.30 ,$933.30 ,$933.30 ,$375.87 ,$612.00 ,$306.00 ,$918.00 ,$765.00 ,$816.00 ,$846.60
Hoopeston Regional Hlth Center,9478070,NM PARATHYROID IMAGING,,78070,341,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,9478185,NM SPLEEN IMAGING ONLY,,78185,341,"$1,260.00 ","$1,260.00 ",$352.80 ,"$1,152.90 ",$882.00 ,"$1,054.62 ","$1,152.90 ","$1,152.90 ","$1,152.90 ",$464.31 ,$756.00 ,$378.00 ,"$1,134.00 ",$945.00 ,"$1,008.00 ","$1,045.80 "
Hoopeston Regional Hlth Center,9478201,NM LIVER IMAGING STATICS ONLY,,78201,341,"$1,140.00 ","$1,140.00 ",$319.20 ,"$1,043.10 ",$798.00 ,$954.18 ,"$1,043.10 ","$1,043.10 ","$1,043.10 ",$420.09 ,$684.00 ,$342.00 ,"$1,026.00 ",$855.00 ,$912.00 ,$946.20
Hoopeston Regional Hlth Center,9478202,NM HEMANGIOMA W/FLOW,,78202,341,"$1,420.00 ","$1,420.00 ",$397.60 ,"$1,299.30 ",$994.00 ,"$1,188.54 ","$1,299.30 ","$1,299.30 ","$1,299.30 ",$523.27 ,$852.00 ,$426.00 ,"$1,278.00 ","$1,065.00 ","$1,136.00 ","$1,178.60 "
Hoopeston Regional Hlth Center,9478205,NM SPECT LIVER,,78205,341,"$1,360.00 ","$1,360.00 ",$380.80 ,"$1,244.40 ",$952.00 ,"$1,138.32 ","$1,244.40 ","$1,244.40 ","$1,244.40 ",$501.16 ,$816.00 ,$408.00 ,"$1,224.00 ","$1,020.00 ","$1,088.00 ","$1,128.80 "
Hoopeston Regional Hlth Center,9478215,NM LIVER SPLEEN STATIC IMAGES ONLY,,78215,341,"$1,170.00 ","$1,170.00 ",$327.60 ,"$1,070.55 ",$819.00 ,$979.29 ,"$1,070.55 ","$1,070.55 ","$1,070.55 ",$431.15 ,$702.00 ,$351.00 ,"$1,053.00 ",$877.50 ,$936.00 ,$971.10
Hoopeston Regional Hlth Center,9478216,NM LIVER/SPLEEN VASCULAR FLOW/STATIC,,78216,341,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,9478226,NM HEPATOBILIARY SERIAL IMAGES,,78226,341,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,9478227,NM HIDA SCAN (GB) (HEPATOBILIARY W/ EF),,78227,341,"$2,180.00 ","$2,180.00 ",$610.40 ,"$1,994.70 ","$1,526.00 ","$1,824.66 ","$1,994.70 ","$1,994.70 ","$1,994.70 ",$803.33 ,"$1,308.00 ",$654.00 ,"$1,962.00 ","$1,635.00 ","$1,744.00 ","$1,809.40 "
Hoopeston Regional Hlth Center,9478231,NM SALIVARY GLAND SERIAL IMAGES,,78231,341,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,9478258,NM ESOPHAGEAL MOTILITY,,78258,341,"$1,340.00 ","$1,340.00 ",$375.20 ,"$1,226.10 ",$938.00 ,"$1,121.58 ","$1,226.10 ","$1,226.10 ","$1,226.10 ",$493.79 ,$804.00 ,$402.00 ,"$1,206.00 ","$1,005.00 ","$1,072.00 ","$1,112.20 "
Hoopeston Regional Hlth Center,9478262,NM GASTROESHAGEAL REFLUX,,78262,341,"$1,480.00 ","$1,480.00 ",$414.40 ,"$1,354.20 ","$1,036.00 ","$1,238.76 ","$1,354.20 ","$1,354.20 ","$1,354.20 ",$545.38 ,$888.00 ,$444.00 ,"$1,332.00 ","$1,110.00 ","$1,184.00 ","$1,228.40 "
Hoopeston Regional Hlth Center,9478264,NM GASTRIC EMPTYING,,78264,341,"$1,640.00 ","$1,640.00 ",$459.20 ,"$1,500.60 ","$1,148.00 ","$1,372.68 ","$1,500.60 ","$1,500.60 ","$1,500.60 ",$604.34 ,$984.00 ,$492.00 ,"$1,476.00 ","$1,230.00 ","$1,312.00 ","$1,361.20 "
Hoopeston Regional Hlth Center,9478278,NM GI BLEED,,78278,341,"$1,660.00 ","$1,660.00 ",$464.80 ,"$1,518.90 ","$1,162.00 ","$1,389.42 ","$1,518.90 ","$1,518.90 ","$1,518.90 ",$611.71 ,$996.00 ,$498.00 ,"$1,494.00 ","$1,245.00 ","$1,328.00 ","$1,377.80 "
Hoopeston Regional Hlth Center,9478290,NM MECKELS DIVERTICULUM,,78290,341,"$1,660.00 ","$1,660.00 ",$464.80 ,"$1,518.90 ","$1,162.00 ","$1,389.42 ","$1,518.90 ","$1,518.90 ","$1,518.90 ",$611.71 ,$996.00 ,$498.00 ,"$1,494.00 ","$1,245.00 ","$1,328.00 ","$1,377.80 "
Hoopeston Regional Hlth Center,9478300,NM BONE LIMITED SINGLE AREA,,78300,341,$990.00 ,$990.00 ,$277.20 ,$905.85 ,$693.00 ,$828.63 ,$905.85 ,$905.85 ,$905.85 ,$364.82 ,$594.00 ,$297.00 ,$891.00 ,$742.50 ,$792.00 ,$821.70
Hoopeston Regional Hlth Center,9478306,NM BONE SCAN TOTAL BODY,,78306,341,"$1,020.00 ","$1,020.00 ",$285.60 ,$933.30 ,$714.00 ,$853.74 ,$933.30 ,$933.30 ,$933.30 ,$375.87 ,$612.00 ,$306.00 ,$918.00 ,$765.00 ,$816.00 ,$846.60
Hoopeston Regional Hlth Center,9478315,NM BONE 3 PHASE,,78315,341,"$1,670.00 ","$1,670.00 ",$467.60 ,"$1,528.05 ","$1,169.00 ","$1,397.79 ","$1,528.05 ","$1,528.05 ","$1,528.05 ",$615.40 ,"$1,002.00 ",$501.00 ,"$1,503.00 ","$1,252.50 ","$1,336.00 ","$1,386.10 "
Hoopeston Regional Hlth Center,9478320,NM BONE SPECT,,78320,341,"$1,400.00 ","$1,400.00 ",$392.00 ,"$1,281.00 ",$980.00 ,"$1,171.80 ","$1,281.00 ","$1,281.00 ","$1,281.00 ",$515.90 ,$840.00 ,$420.00 ,"$1,260.00 ","$1,050.00 ","$1,120.00 ","$1,162.00 "
Hoopeston Regional Hlth Center,9478451,NM CARDIAC REST OR STRESS,,78451,341,"$1,900.00 ","$1,900.00 ",$532.00 ,"$1,738.50 ","$1,330.00 ","$1,590.30 ","$1,738.50 ","$1,738.50 ","$1,738.50 ",$700.15 ,"$1,140.00 ",$570.00 ,"$1,710.00 ","$1,425.00 ","$1,520.00 ","$1,577.00 "
Hoopeston Regional Hlth Center,9478452,NM CARDIAC REST & STRESS,,78452,341,"$2,700.00 ","$2,700.00 ",$756.00 ,"$2,470.50 ","$1,890.00 ","$2,259.90 ","$2,470.50 ","$2,470.50 ","$2,470.50 ",$994.95 ,"$1,620.00 ",$810.00 ,"$2,430.00 ","$2,025.00 ","$2,160.00 ","$2,241.00 "
Hoopeston Regional Hlth Center,9478472,NM MUGA (GATED EQUILIBRIUM SINGLE),,78472,341,"$1,420.00 ","$1,420.00 ",$397.60 ,"$1,299.30 ",$994.00 ,"$1,188.54 ","$1,299.30 ","$1,299.30 ","$1,299.30 ",$523.27 ,$852.00 ,$426.00 ,"$1,278.00 ","$1,065.00 ","$1,136.00 ","$1,178.60 "
Hoopeston Regional Hlth Center,9478579,NM LUNG VENTAEROSOL MULTIPLE,,78579,341,"$1,290.00 ","$1,290.00 ",$361.20 ,"$1,180.35 ",$903.00 ,"$1,079.73 ","$1,180.35 ","$1,180.35 ","$1,180.35 ",$475.37 ,$774.00 ,$387.00 ,"$1,161.00 ",$967.50 ,"$1,032.00 ","$1,070.70 "
Hoopeston Regional Hlth Center,9478582,NM LUNG PERFUSION LUNG VENTILATION,,78582,341,"$2,070.00 ","$2,070.00 ",$579.60 ,"$1,894.05 ","$1,449.00 ","$1,732.59 ","$1,894.05 ","$1,894.05 ","$1,894.05 ",$762.80 ,"$1,242.00 ",$621.00 ,"$1,863.00 ","$1,552.50 ","$1,656.00 ","$1,718.10 "
Hoopeston Regional Hlth Center,9478597,NM LUNG PERFUSION,,78597,341,"$1,230.00 ","$1,230.00 ",$344.40 ,"$1,125.45 ",$861.00 ,"$1,029.51 ","$1,125.45 ","$1,125.45 ","$1,125.45 ",$453.26 ,$738.00 ,$369.00 ,"$1,107.00 ",$922.50 ,$984.00 ,"$1,020.90 "
Hoopeston Regional Hlth Center,9478707,NM RENAL FUNCTION W/MAGIII,,78707,341,"$1,280.00 ","$1,280.00 ",$358.40 ,"$1,171.20 ",$896.00 ,"$1,071.36 ","$1,171.20 ","$1,171.20 ","$1,171.20 ",$471.68 ,$768.00 ,$384.00 ,"$1,152.00 ",$960.00 ,"$1,024.00 ","$1,062.40 "
Hoopeston Regional Hlth Center,9478708,NM RENAL W/INTERVENTION,,78708,341,$820.00 ,$820.00 ,$229.60 ,$750.30 ,$574.00 ,$686.34 ,$750.30 ,$750.30 ,$750.30 ,$302.17 ,$492.00 ,$246.00 ,$738.00 ,$615.00 ,$656.00 ,$680.60
Hoopeston Regional Hlth Center,9478710,NM RENAL SPECT,,78710,341,"$1,340.00 ","$1,340.00 ",$375.20 ,"$1,226.10 ",$938.00 ,"$1,121.58 ","$1,226.10 ","$1,226.10 ","$1,226.10 ",$493.79 ,$804.00 ,$402.00 ,"$1,206.00 ","$1,005.00 ","$1,072.00 ","$1,112.20 "
Hoopeston Regional Hlth Center,9478740,NM CYSTOGRAM,,78740,341,"$1,360.00 ","$1,360.00 ",$380.80 ,"$1,244.40 ",$952.00 ,"$1,138.32 ","$1,244.40 ","$1,244.40 ","$1,244.40 ",$501.16 ,$816.00 ,$408.00 ,"$1,224.00 ","$1,020.00 ","$1,088.00 ","$1,128.80 "
Hoopeston Regional Hlth Center,9478761,NM TESTICULAR SCAN W/FLOW STUDY,,78761,341,"$1,240.00 ","$1,240.00 ",$347.20 ,"$1,134.60 ",$868.00 ,"$1,037.88 ","$1,134.60 ","$1,134.60 ","$1,134.60 ",$456.94 ,$744.00 ,$372.00 ,"$1,116.00 ",$930.00 ,$992.00 ,"$1,029.20 "
Hoopeston Regional Hlth Center,9478803,NM PARATHYROID TOMOGRAPHY,,78803,341,$950.00 ,$950.00 ,$266.00 ,$869.25 ,$665.00 ,$795.15 ,$869.25 ,$869.25 ,$869.25 ,$350.08 ,$570.00 ,$285.00 ,$855.00 ,$712.50 ,$760.00 ,$788.50
Hoopeston Regional Hlth Center,9409560,NM TC99MLABELED RED BLOOD CELLS-UP TO 30,,A9560,341,$220.00 ,$220.00 ,$61.60 ,$201.30 ,$154.00 ,$184.14 ,$201.30 ,$201.30 ,$201.30 ,$81.07 ,$132.00 ,$66.00 ,$198.00 ,$165.00 ,$176.00 ,$182.60
Hoopeston Regional Hlth Center,9402805,NM CCK (KINEVAC),,J2805,341,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9478630,CSF FLUID SCAN CISTERNOGRAPHY,,78630,341,"$2,260.00 ","$2,260.00 ",$632.80 ,"$2,067.90 ","$1,582.00 ","$1,891.62 ","$2,067.90 ","$2,067.90 ","$2,067.90 ",$832.81 ,"$1,356.00 ",$678.00 ,"$2,034.00 ","$1,695.00 ","$1,808.00 ","$1,875.80 "
Hoopeston Regional Hlth Center,9478453,NM CARDIAC PLANAR REST OR STRESS,,78453,341,"$1,770.00 ","$1,770.00 ",$495.60 ,"$1,619.55 ","$1,239.00 ","$1,481.49 ","$1,619.55 ","$1,619.55 ","$1,619.55 ",$652.25 ,"$1,062.00 ",$531.00 ,"$1,593.00 ","$1,327.50 ","$1,416.00 ","$1,469.10 "
Hoopeston Regional Hlth Center,9478071,PARATHYROID IMAGING W/SPECT,,78071,341,"$1,280.00 ","$1,280.00 ",$358.40 ,"$1,171.20 ",$896.00 ,"$1,071.36 ","$1,171.20 ","$1,171.20 ","$1,171.20 ",$471.68 ,$768.00 ,$384.00 ,"$1,152.00 ",$960.00 ,"$1,024.00 ","$1,062.40 "
Hoopeston Regional Hlth Center,9409567,TECHNETIUM TC-99M AEROSOL,,A9567,343,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9409500,TC 99M SESTAMIBI,,A9500,343,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9409503,NM TC 99M MEDRONATE (MDP)-UP TO 30MCI,,A9503,343,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9409512,NM TC 99M PERTECHNEATE - PER MCI,,A9512,343,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9409516,NM IODINE I 123 PER 100MG UP TO 999 MCI,,A9516,343,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9409537,NM TC 99M MEBROFENIN (CHOLETECH)-UP TO 1,,A9537,343,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9409539,NM TC 99 PENTETATE - UP TO 25MCI,,A9539,343,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,9409540,NM TC 99 MACROAGGREGATED ALBUMIN -UP 10,,A9540,343,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9409541,NM TC99M SULFUR COLLAID -UP TO 20,,A9541,343,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,9409562,NM TC 99M MERTIATIDE UP TO 15MCI,,A9562,343,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9419516,NM IODINE I 123 PER 100MG UP TO 999 MCI,,A9516,343,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9409502,TC 99M TETROFOSMIN UP TO 40MCI,,A9502,343,$325.00 ,$325.00 ,$91.00 ,$297.38 ,$227.50 ,$272.03 ,$297.38 ,$297.38 ,$297.38 ,$119.76 ,$195.00 ,$97.50 ,$292.50 ,$243.75 ,$260.00 ,$269.75
Hoopeston Regional Hlth Center,9419502,TC 99M TETROFOSMIN UP TO 40MCI,,A9502,343,$325.00 ,$325.00 ,$91.00 ,$297.38 ,$227.50 ,$272.03 ,$297.38 ,$297.38 ,$297.38 ,$119.76 ,$195.00 ,$97.50 ,$292.50 ,$243.75 ,$260.00 ,$269.75
Hoopeston Regional Hlth Center,9419503,NM TC 99M MEDRONATE (MDP)-UP TO 30MCI,,A9503,343,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9419537,TC 99M MEBROFENIN UP TO 15MCI,,A9537,343,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9409558,133 XENON 20 MCI,,A9558,343,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9401541,NM TC99M SULFUR COLLAID -UP TO 20,,A9541,343,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,9402541,NM TC99M SULFUR COLLAID -UP TO 20,,A9541,343,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,9409592,"COPPER CU-64, DOTATATE, DIAGNOSTIC, 1 MILLICURIE",,A9592,343,"$16,650.00 ","$16,650.00 ","$4,662.00 ","$15,234.75 ","$11,655.00 ","$13,936.05 ","$15,234.75 ","$15,234.75 ","$15,234.75 ","$6,135.53 ","$9,990.00 ","$4,995.00 ","$14,985.00 ","$12,487.50 ","$13,320.00 ","$13,819.50 "
Hoopeston Regional Hlth Center,9476377,3D RENDERING W/POST-PROCESSING,,76377,350,"$1,200.00 ","$1,200.00 ",$336.00 ,"$1,098.00 ",$840.00 ,"$1,004.40 ","$1,098.00 ","$1,098.00 ","$1,098.00 ",$442.20 ,$720.00 ,$360.00 ,"$1,080.00 ",$900.00 ,$960.00 ,$996.00
Hoopeston Regional Hlth Center,9470480,CT ORBIT/SEL WO CONTRAST,,70480,350,"$2,390.00 ","$2,390.00 ",$669.20 ,"$2,186.85 ","$1,673.00 ","$2,000.43 ","$2,186.85 ","$2,186.85 ","$2,186.85 ",$880.72 ,"$1,434.00 ",$717.00 ,"$2,151.00 ","$1,792.50 ","$1,912.00 ","$1,983.70 "
Hoopeston Regional Hlth Center,9410480,CT EAR WO CONTRAST,,70480,350,"$2,390.00 ","$2,390.00 ",$669.20 ,"$2,186.85 ","$1,673.00 ","$2,000.43 ","$2,186.85 ","$2,186.85 ","$2,186.85 ",$880.72 ,"$1,434.00 ",$717.00 ,"$2,151.00 ","$1,792.50 ","$1,912.00 ","$1,983.70 "
Hoopeston Regional Hlth Center,9420480,CT COCHLEA BILATERAL,,70480,350,"$2,390.00 ","$2,390.00 ",$669.20 ,"$2,186.85 ","$1,673.00 ","$2,000.43 ","$2,186.85 ","$2,186.85 ","$2,186.85 ",$880.72 ,"$1,434.00 ",$717.00 ,"$2,151.00 ","$1,792.50 ","$1,912.00 ","$1,983.70 "
Hoopeston Regional Hlth Center,9470481,CT ORBIT/SEL W CONTRAST,,70481,350,"$2,120.00 ","$2,120.00 ",$593.60 ,"$1,939.80 ","$1,484.00 ","$1,774.44 ","$1,939.80 ","$1,939.80 ","$1,939.80 ",$781.22 ,"$1,272.00 ",$636.00 ,"$1,908.00 ","$1,590.00 ","$1,696.00 ","$1,759.60 "
Hoopeston Regional Hlth Center,9410481,CT EAR W CONTRAST,,70481,350,"$2,120.00 ","$2,120.00 ",$593.60 ,"$1,939.80 ","$1,484.00 ","$1,774.44 ","$1,939.80 ","$1,939.80 ","$1,939.80 ",$781.22 ,"$1,272.00 ",$636.00 ,"$1,908.00 ","$1,590.00 ","$1,696.00 ","$1,759.60 "
Hoopeston Regional Hlth Center,9470482,CT ORBIT/SEL W/WO CONTRAST,,70482,350,"$2,660.00 ","$2,660.00 ",$744.80 ,"$2,433.90 ","$1,862.00 ","$2,226.42 ","$2,433.90 ","$2,433.90 ","$2,433.90 ",$980.21 ,"$1,596.00 ",$798.00 ,"$2,394.00 ","$1,995.00 ","$2,128.00 ","$2,207.80 "
Hoopeston Regional Hlth Center,9470486,CT MAXILLOFAC WO CONTRAST,,70486,350,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,9410486,CT FOOT LT W CONTRAST,,70486,350,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,9420486,CT SINUS,,70486,350,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,9470487,CT MAXILLOFAC W CONTRAST,,70487,350,"$2,000.00 ","$2,000.00 ",$560.00 ,"$1,830.00 ","$1,400.00 ","$1,674.00 ","$1,830.00 ","$1,830.00 ","$1,830.00 ",$737.00 ,"$1,200.00 ",$600.00 ,"$1,800.00 ","$1,500.00 ","$1,600.00 ","$1,660.00 "
Hoopeston Regional Hlth Center,9470488,CT MAXILLOFAC W/WO CONTRAST,,70488,350,"$2,380.00 ","$2,380.00 ",$666.40 ,"$2,177.70 ","$1,666.00 ","$1,992.06 ","$2,177.70 ","$2,177.70 ","$2,177.70 ",$877.03 ,"$1,428.00 ",$714.00 ,"$2,142.00 ","$1,785.00 ","$1,904.00 ","$1,975.40 "
Hoopeston Regional Hlth Center,9470490,CT NECK ST WO CONTRAST,,70490,350,"$1,980.00 ","$1,980.00 ",$554.40 ,"$1,811.70 ","$1,386.00 ","$1,657.26 ","$1,811.70 ","$1,811.70 ","$1,811.70 ",$729.63 ,"$1,188.00 ",$594.00 ,"$1,782.00 ","$1,485.00 ","$1,584.00 ","$1,643.40 "
Hoopeston Regional Hlth Center,9470491,CT NECK ST W CONTRAST,,70491,350,"$2,690.00 ","$2,690.00 ",$753.20 ,"$2,461.35 ","$1,883.00 ","$2,251.53 ","$2,461.35 ","$2,461.35 ","$2,461.35 ",$991.27 ,"$1,614.00 ",$807.00 ,"$2,421.00 ","$2,017.50 ","$2,152.00 ","$2,232.70 "
Hoopeston Regional Hlth Center,9470492,CT NECK ST W/WO CONTRAST,,70492,350,"$2,540.00 ","$2,540.00 ",$711.20 ,"$2,324.10 ","$1,778.00 ","$2,125.98 ","$2,324.10 ","$2,324.10 ","$2,324.10 ",$935.99 ,"$1,524.00 ",$762.00 ,"$2,286.00 ","$1,905.00 ","$2,032.00 ","$2,108.20 "
Hoopeston Regional Hlth Center,9471250,CT CHEST WO CONTRAST,,71250,350,"$2,720.00 ","$2,720.00 ",$761.60 ,"$2,488.80 ","$1,904.00 ","$2,276.64 ","$2,488.80 ","$2,488.80 ","$2,488.80 ","$1,002.32 ","$1,632.00 ",$816.00 ,"$2,448.00 ","$2,040.00 ","$2,176.00 ","$2,257.60 "
Hoopeston Regional Hlth Center,9411250,CT CHEST BRONCHIECTASIS,,71250,350,"$2,290.00 ","$2,290.00 ",$641.20 ,"$2,095.35 ","$1,603.00 ","$1,916.73 ","$2,095.35 ","$2,095.35 ","$2,095.35 ",$843.87 ,"$1,374.00 ",$687.00 ,"$2,061.00 ","$1,717.50 ","$1,832.00 ","$1,900.70 "
Hoopeston Regional Hlth Center,9471260,CT CHEST W CONTRAST,,71260,350,"$2,700.00 ","$2,700.00 ",$756.00 ,"$2,470.50 ","$1,890.00 ","$2,259.90 ","$2,470.50 ","$2,470.50 ","$2,470.50 ",$994.95 ,"$1,620.00 ",$810.00 ,"$2,430.00 ","$2,025.00 ","$2,160.00 ","$2,241.00 "
Hoopeston Regional Hlth Center,9471270,CT CHEST W/WO CONTRAST,,71270,350,"$3,610.00 ","$3,610.00 ","$1,010.80 ","$3,303.15 ","$2,527.00 ","$3,021.57 ","$3,303.15 ","$3,303.15 ","$3,303.15 ","$1,330.29 ","$2,166.00 ","$1,083.00 ","$3,249.00 ","$2,707.50 ","$2,888.00 ","$2,996.30 "
Hoopeston Regional Hlth Center,9471275,CT ANGIO CHEST W CONTRAST,,71275,350,"$4,020.00 ","$4,020.00 ","$1,125.60 ","$3,678.30 ","$2,814.00 ","$3,364.74 ","$3,678.30 ","$3,678.30 ","$3,678.30 ","$1,481.37 ","$2,412.00 ","$1,206.00 ","$3,618.00 ","$3,015.00 ","$3,216.00 ","$3,336.60 "
Hoopeston Regional Hlth Center,9472125,CT SPINE CERVICAL W/O CONTRAST,,72125,350,"$2,560.00 ","$2,560.00 ",$716.80 ,"$2,342.40 ","$1,792.00 ","$2,142.72 ","$2,342.40 ","$2,342.40 ","$2,342.40 ",$943.36 ,"$1,536.00 ",$768.00 ,"$2,304.00 ","$1,920.00 ","$2,048.00 ","$2,124.80 "
Hoopeston Regional Hlth Center,9472127,CT SPINE CERVICAL WO/W CONTRAST,,72127,350,"$2,740.00 ","$2,740.00 ",$767.20 ,"$2,507.10 ","$1,918.00 ","$2,293.38 ","$2,507.10 ","$2,507.10 ","$2,507.10 ","$1,009.69 ","$1,644.00 ",$822.00 ,"$2,466.00 ","$2,055.00 ","$2,192.00 ","$2,274.20 "
Hoopeston Regional Hlth Center,9472128,CT SPINE THORACIC W/O CONTRAST,,72128,350,"$2,200.00 ","$2,200.00 ",$616.00 ,"$2,013.00 ","$1,540.00 ","$1,841.40 ","$2,013.00 ","$2,013.00 ","$2,013.00 ",$810.70 ,"$1,320.00 ",$660.00 ,"$1,980.00 ","$1,650.00 ","$1,760.00 ","$1,826.00 "
Hoopeston Regional Hlth Center,9472129,CT SPINE THORACIC W CONTRAST,,72129,350,"$2,540.00 ","$2,540.00 ",$711.20 ,"$2,324.10 ","$1,778.00 ","$2,125.98 ","$2,324.10 ","$2,324.10 ","$2,324.10 ",$935.99 ,"$1,524.00 ",$762.00 ,"$2,286.00 ","$1,905.00 ","$2,032.00 ","$2,108.20 "
Hoopeston Regional Hlth Center,9472130,CT SPINE THORACIC W/WO CONTRAST,,72130,350,"$2,930.00 ","$2,930.00 ",$820.40 ,"$2,680.95 ","$2,051.00 ","$2,452.41 ","$2,680.95 ","$2,680.95 ","$2,680.95 ","$1,079.71 ","$1,758.00 ",$879.00 ,"$2,637.00 ","$2,197.50 ","$2,344.00 ","$2,431.90 "
Hoopeston Regional Hlth Center,9472131,CT SPINE LUMBAR W/O CONTRAST,,72131,350,"$2,360.00 ","$2,360.00 ",$660.80 ,"$2,159.40 ","$1,652.00 ","$1,975.32 ","$2,159.40 ","$2,159.40 ","$2,159.40 ",$869.66 ,"$1,416.00 ",$708.00 ,"$2,124.00 ","$1,770.00 ","$1,888.00 ","$1,958.80 "
Hoopeston Regional Hlth Center,9472132,CT SPINE LUMBAR W CONTRAST,,72132,350,"$2,820.00 ","$2,820.00 ",$789.60 ,"$2,580.30 ","$1,974.00 ","$2,360.34 ","$2,580.30 ","$2,580.30 ","$2,580.30 ","$1,039.17 ","$1,692.00 ",$846.00 ,"$2,538.00 ","$2,115.00 ","$2,256.00 ","$2,340.60 "
Hoopeston Regional Hlth Center,9472133,CT SPINE LUMBAR WO/W CONTRAST,,72133,350,"$2,690.00 ","$2,690.00 ",$753.20 ,"$2,461.35 ","$1,883.00 ","$2,251.53 ","$2,461.35 ","$2,461.35 ","$2,461.35 ",$991.27 ,"$1,614.00 ",$807.00 ,"$2,421.00 ","$2,017.50 ","$2,152.00 ","$2,232.70 "
Hoopeston Regional Hlth Center,9472192,CT PELVIS OR SACRUM/COCCYX WO CTRST,,72192,350,"$2,280.00 ","$2,280.00 ",$638.40 ,"$2,086.20 ","$1,596.00 ","$1,908.36 ","$2,086.20 ","$2,086.20 ","$2,086.20 ",$840.18 ,"$1,368.00 ",$684.00 ,"$2,052.00 ","$1,710.00 ","$1,824.00 ","$1,892.40 "
Hoopeston Regional Hlth Center,9472193,CT PELVIS W CONTRAST,,72193,350,"$2,800.00 ","$2,800.00 ",$784.00 ,"$2,562.00 ","$1,960.00 ","$2,343.60 ","$2,562.00 ","$2,562.00 ","$2,562.00 ","$1,031.80 ","$1,680.00 ",$840.00 ,"$2,520.00 ","$2,100.00 ","$2,240.00 ","$2,324.00 "
Hoopeston Regional Hlth Center,9472194,CT PELVIS W/WO CONTRAST,,72194,350,"$3,130.00 ","$3,130.00 ",$876.40 ,"$2,863.95 ","$2,191.00 ","$2,619.81 ","$2,863.95 ","$2,863.95 ","$2,863.95 ","$1,153.41 ","$1,878.00 ",$939.00 ,"$2,817.00 ","$2,347.50 ","$2,504.00 ","$2,597.90 "
Hoopeston Regional Hlth Center,9474150,CT ABDOMEN W/O CONTRAST,,74150,350,"$3,230.00 ","$3,230.00 ",$904.40 ,"$2,955.45 ","$2,261.00 ","$2,703.51 ","$2,955.45 ","$2,955.45 ","$2,955.45 ","$1,190.26 ","$1,938.00 ",$969.00 ,"$2,907.00 ","$2,422.50 ","$2,584.00 ","$2,680.90 "
Hoopeston Regional Hlth Center,9474160,CT ABDOMEN W/CONTRAST,,74160,350,"$3,560.00 ","$3,560.00 ",$996.80 ,"$3,257.40 ","$2,492.00 ","$2,979.72 ","$3,257.40 ","$3,257.40 ","$3,257.40 ","$1,311.86 ","$2,136.00 ","$1,068.00 ","$3,204.00 ","$2,670.00 ","$2,848.00 ","$2,954.80 "
Hoopeston Regional Hlth Center,9474170,CT ABDOMEN W/WO CONTRAST,,74170,350,"$3,970.00 ","$3,970.00 ","$1,111.60 ","$3,632.55 ","$2,779.00 ","$3,322.89 ","$3,632.55 ","$3,632.55 ","$3,632.55 ","$1,462.95 ","$2,382.00 ","$1,191.00 ","$3,573.00 ","$2,977.50 ","$3,176.00 ","$3,295.10 "
Hoopeston Regional Hlth Center,9474176,CT ABD&PELVIS WO CONTRAST,,74176,350,"$4,920.00 ","$4,920.00 ","$1,377.60 ","$4,501.80 ","$3,444.00 ","$4,118.04 ","$4,501.80 ","$4,501.80 ","$4,501.80 ","$1,813.02 ","$2,952.00 ","$1,476.00 ","$4,428.00 ","$3,690.00 ","$3,936.00 ","$4,083.60 "
Hoopeston Regional Hlth Center,9474177,CT ABD&PELVIS W CONTRAST,,74177,350,"$5,720.00 ","$5,720.00 ","$1,601.60 ","$5,233.80 ","$4,004.00 ","$4,787.64 ","$5,233.80 ","$5,233.80 ","$5,233.80 ","$2,107.82 ","$3,432.00 ","$1,716.00 ","$5,148.00 ","$4,290.00 ","$4,576.00 ","$4,747.60 "
Hoopeston Regional Hlth Center,9474178,CT ABD&PELVIS WO/W CONTRAST,,74178,350,"$6,460.00 ","$6,460.00 ","$1,808.80 ","$5,910.90 ","$4,522.00 ","$5,407.02 ","$5,910.90 ","$5,910.90 ","$5,910.90 ","$2,380.51 ","$3,876.00 ","$1,938.00 ","$5,814.00 ","$4,845.00 ","$5,168.00 ","$5,361.80 "
Hoopeston Regional Hlth Center,9477073,CT SCANOGRAM BONE LENGTH STUDY,,77073,350,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9473200,CT UPPER EXT WO CONTRAST LEFT,,73200,350,"$2,160.00 ","$2,160.00 ",$604.80 ,"$1,976.40 ","$1,512.00 ","$1,807.92 ","$1,976.40 ","$1,976.40 ","$1,976.40 ",$795.96 ,"$1,296.00 ",$648.00 ,"$1,944.00 ","$1,620.00 ","$1,728.00 ","$1,792.80 "
Hoopeston Regional Hlth Center,9403200,CT UPPER EXT WO CONTRAST RIGHT,,73200,350,"$1,830.00 ","$1,830.00 ",$512.40 ,"$1,674.45 ","$1,281.00 ","$1,531.71 ","$1,674.45 ","$1,674.45 ","$1,674.45 ",$674.36 ,"$1,098.00 ",$549.00 ,"$1,647.00 ","$1,372.50 ","$1,464.00 ","$1,518.90 "
Hoopeston Regional Hlth Center,9473700,CT LOWER EXT WO CONTRAST LEFT,,73700,350,"$1,810.00 ","$1,810.00 ",$506.80 ,"$1,656.15 ","$1,267.00 ","$1,514.97 ","$1,656.15 ","$1,656.15 ","$1,656.15 ",$666.99 ,"$1,086.00 ",$543.00 ,"$1,629.00 ","$1,357.50 ","$1,448.00 ","$1,502.30 "
Hoopeston Regional Hlth Center,9403700,CT LOWER EXT WO CONTRAST RIGHT,,73700,350,"$1,000.00 ","$1,000.00 ",$280.00 ,$915.00 ,$700.00 ,$837.00 ,$915.00 ,$915.00 ,$915.00 ,$368.50 ,$600.00 ,$300.00 ,$900.00 ,$750.00 ,$800.00 ,$830.00
Hoopeston Regional Hlth Center,9474175,CT ANGIOGRAPHY ABDOMEN W/CONTRAST,,74175,350,"$3,720.00 ","$3,720.00 ","$1,041.60 ","$3,403.80 ","$2,604.00 ","$3,113.64 ","$3,403.80 ","$3,403.80 ","$3,403.80 ","$1,370.82 ","$2,232.00 ","$1,116.00 ","$3,348.00 ","$2,790.00 ","$2,976.00 ","$3,087.60 "
Hoopeston Regional Hlth Center,9470498,CT ANGIOGRAPHY -NECK,,70498,350,"$3,970.00 ","$3,970.00 ","$1,111.60 ","$3,632.55 ","$2,779.00 ","$3,322.89 ","$3,632.55 ","$3,632.55 ","$3,632.55 ","$1,462.95 ","$2,382.00 ","$1,191.00 ","$3,573.00 ","$2,977.50 ","$3,176.00 ","$3,295.10 "
Hoopeston Regional Hlth Center,9474174,CT ANGIOGRAPHY ABD & PELVIS W/CONTRAST,,74174,350,"$5,000.00 ","$5,000.00 ","$1,400.00 ","$4,575.00 ","$3,500.00 ","$4,185.00 ","$4,575.00 ","$4,575.00 ","$4,575.00 ","$1,842.50 ","$3,000.00 ","$1,500.00 ","$4,500.00 ","$3,750.00 ","$4,000.00 ","$4,150.00 "
Hoopeston Regional Hlth Center,9476376,3D RENDERING W/O POST-PROCESS,,76376,350,"$1,010.00 ","$1,010.00 ",$282.80 ,$924.15 ,$707.00 ,$845.37 ,$924.15 ,$924.15 ,$924.15 ,$372.19 ,$606.00 ,$303.00 ,$909.00 ,$757.50 ,$808.00 ,$838.30
Hoopeston Regional Hlth Center,9473701,CT LOWER EXTREMITY W/CONTRAST,,73701,350,"$2,200.00 ","$2,200.00 ",$616.00 ,"$2,013.00 ","$1,540.00 ","$1,841.40 ","$2,013.00 ","$2,013.00 ","$2,013.00 ",$810.70 ,"$1,320.00 ",$660.00 ,"$1,980.00 ","$1,650.00 ","$1,760.00 ","$1,826.00 "
Hoopeston Regional Hlth Center,9475635,CT ANGIO ABD AORTA & RUNOFF,,75635,350,"$5,000.00 ","$5,000.00 ","$1,400.00 ","$4,575.00 ","$3,500.00 ","$4,185.00 ","$4,575.00 ","$4,575.00 ","$4,575.00 ","$1,842.50 ","$3,000.00 ","$1,500.00 ","$4,500.00 ","$3,750.00 ","$4,000.00 ","$4,150.00 "
Hoopeston Regional Hlth Center,9470496,CT ANGIOGRAPHY -HEAD,,70496,350,"$5,600.00 ","$5,600.00 ","$1,568.00 ","$5,124.00 ","$3,920.00 ","$4,687.20 ","$5,124.00 ","$5,124.00 ","$5,124.00 ","$2,063.60 ","$3,360.00 ","$1,680.00 ","$5,040.00 ","$4,200.00 ","$4,480.00 ","$4,648.00 "
Hoopeston Regional Hlth Center,9473201,CT SCAN OF ARM CONTRAST,,73201,350,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9400297,LDCT FOR LUNG SCREENING,,G0297,350,"$3,070.00 ","$3,070.00 ",$859.60 ,"$2,809.05 ","$2,149.00 ","$2,569.59 ","$2,809.05 ","$2,809.05 ","$2,809.05 ","$1,131.30 ","$1,842.00 ",$921.00 ,"$2,763.00 ","$2,302.50 ","$2,456.00 ","$2,548.10 "
Hoopeston Regional Hlth Center,9471271,COMPUTED TOMOGRAPHY THORAX LW DOSE LNG CA SCR C-,,71271,350,$475.00 ,$475.00 ,$133.00 ,$434.63 ,$332.50 ,$397.58 ,$434.63 ,$434.63 ,$434.63 ,$175.04 ,$285.00 ,$142.50 ,$427.50 ,$356.25 ,$380.00 ,$394.25
Hoopeston Regional Hlth Center,9472126,CT CERVICAL SPINE W/CONTRAST,,72126,350,"$3,220.00 ","$3,220.00 ",$901.60 ,"$2,946.30 ","$2,254.00 ","$2,695.14 ","$2,946.30 ","$2,946.30 ","$2,946.30 ","$1,186.57 ","$1,932.00 ",$966.00 ,"$2,898.00 ","$2,415.00 ","$2,576.00 ","$2,672.60 "
Hoopeston Regional Hlth Center,9470450,CT HEAD WO CONTRAST,,70450,351,"$2,590.00 ","$2,590.00 ",$725.20 ,"$2,369.85 ","$1,813.00 ","$2,167.83 ","$2,369.85 ","$2,369.85 ","$2,369.85 ",$954.42 ,"$1,554.00 ",$777.00 ,"$2,331.00 ","$1,942.50 ","$2,072.00 ","$2,149.70 "
Hoopeston Regional Hlth Center,9470460,CT HEAD W CONTRAST,,70460,351,"$2,320.00 ","$2,320.00 ",$649.60 ,"$2,122.80 ","$1,624.00 ","$1,941.84 ","$2,122.80 ","$2,122.80 ","$2,122.80 ",$854.92 ,"$1,392.00 ",$696.00 ,"$2,088.00 ","$1,740.00 ","$1,856.00 ","$1,925.60 "
Hoopeston Regional Hlth Center,9470470,CT HEAD WO/W CONTRAST,,70470,351,"$3,450.00 ","$3,450.00 ",$966.00 ,"$3,156.75 ","$2,415.00 ","$2,887.65 ","$3,156.75 ","$3,156.75 ","$3,156.75 ","$1,271.33 ","$2,070.00 ","$1,035.00 ","$3,105.00 ","$2,587.50 ","$2,760.00 ","$2,863.50 "
Hoopeston Regional Hlth Center,9100200,OR ROOM LEVEL 1 1ST 15 MINS,,,360,"$2,470.00 ","$2,470.00 ",$691.60 ,"$2,260.05 ","$1,729.00 ","$2,067.39 ","$2,260.05 ","$2,260.05 ","$2,260.05 ",$910.20 ,"$1,482.00 ",$741.00 ,"$2,223.00 ","$1,852.50 ","$1,976.00 ","$2,050.10 "
Hoopeston Regional Hlth Center,9100201,OR ROOM LEVEL 1 EA ADD 1 MIN,,,360,$64.00 ,$64.00 ,$17.92 ,$58.56 ,$44.80 ,$53.57 ,$58.56 ,$58.56 ,$58.56 ,$23.58 ,$38.40 ,$19.20 ,$57.60 ,$48.00 ,$51.20 ,$53.12
Hoopeston Regional Hlth Center,9100202,OR ROOM LEVEL 2 1ST 15 MINS,,,360,"$2,510.00 ","$2,510.00 ",$702.80 ,"$2,296.65 ","$1,757.00 ","$2,100.87 ","$2,296.65 ","$2,296.65 ","$2,296.65 ",$924.94 ,"$1,506.00 ",$753.00 ,"$2,259.00 ","$1,882.50 ","$2,008.00 ","$2,083.30 "
Hoopeston Regional Hlth Center,9100203,OR ROOM LEVEL 2 EA ADD 1 MIN,,,360,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9100204,OR ROOM LEVEL 3 1ST 15 MINS,,,360,"$2,130.00 ","$2,130.00 ",$596.40 ,"$1,948.95 ","$1,491.00 ","$1,782.81 ","$1,948.95 ","$1,948.95 ","$1,948.95 ",$784.91 ,"$1,278.00 ",$639.00 ,"$1,917.00 ","$1,597.50 ","$1,704.00 ","$1,767.90 "
Hoopeston Regional Hlth Center,9100205,OR ROOM LEVEL 3 EA ADD 1 MIN,,,360,$56.00 ,$56.00 ,$15.68 ,$51.24 ,$39.20 ,$46.87 ,$51.24 ,$51.24 ,$51.24 ,$20.64 ,$33.60 ,$16.80 ,$50.40 ,$42.00 ,$44.80 ,$46.48
Hoopeston Regional Hlth Center,9100206,OR ROOM LEVEL 4 1ST 15 MINS,,,360,"$1,820.00 ","$1,820.00 ",$509.60 ,"$1,665.30 ","$1,274.00 ","$1,523.34 ","$1,665.30 ","$1,665.30 ","$1,665.30 ",$670.67 ,"$1,092.00 ",$546.00 ,"$1,638.00 ","$1,365.00 ","$1,456.00 ","$1,510.60 "
Hoopeston Regional Hlth Center,9100207,OR ROOM LEVEL 4 EA ADD 1 MIN,,,360,$46.00 ,$46.00 ,$12.88 ,$42.09 ,$32.20 ,$38.50 ,$42.09 ,$42.09 ,$42.09 ,$16.95 ,$27.60 ,$13.80 ,$41.40 ,$34.50 ,$36.80 ,$38.18
Hoopeston Regional Hlth Center,9100004,LITHROTRIPSY,,,360,"$1,630.00 ","$1,630.00 ",$456.40 ,"$1,491.45 ","$1,141.00 ","$1,364.31 ","$1,491.45 ","$1,491.45 ","$1,491.45 ",$600.66 ,$978.00 ,$489.00 ,"$1,467.00 ","$1,222.50 ","$1,304.00 ","$1,352.90 "
Hoopeston Regional Hlth Center,9100005,SLT LASER PROCEDURE,,,360,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9100006,YAG LASER PROCEDURE,,,360,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9100007,HOLMIUM LASTER,,,360,"$1,210.00 ","$1,210.00 ",$338.80 ,"$1,107.15 ",$847.00 ,"$1,012.77 ","$1,107.15 ","$1,107.15 ","$1,107.15 ",$445.89 ,$726.00 ,$363.00 ,"$1,089.00 ",$907.50 ,$968.00 ,"$1,004.30 "
Hoopeston Regional Hlth Center,9100008,NIM NERVE STIMULATORY,,,360,"$4,850.00 ","$4,850.00 ","$1,358.00 ","$4,437.75 ","$3,395.00 ","$4,059.45 ","$4,437.75 ","$4,437.75 ","$4,437.75 ","$1,787.23 ","$2,910.00 ","$1,455.00 ","$4,365.00 ","$3,637.50 ","$3,880.00 ","$4,025.50 "
Hoopeston Regional Hlth Center,9100009,GREEN LIGHT LASER,,,360,"$2,260.00 ","$2,260.00 ",$632.80 ,"$2,067.90 ","$1,582.00 ","$1,891.62 ","$2,067.90 ","$2,067.90 ","$2,067.90 ",$832.81 ,"$1,356.00 ",$678.00 ,"$2,034.00 ","$1,695.00 ","$1,808.00 ","$1,875.80 "
Hoopeston Regional Hlth Center,9100011,CYSTOSCOPE AND LENS,,,360,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9100012,ARGON LASER,,,360,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9100013,PHACO MACHINE,,,360,"$1,220.00 ","$1,220.00 ",$341.60 ,"$1,116.30 ",$854.00 ,"$1,021.14 ","$1,116.30 ","$1,116.30 ","$1,116.30 ",$449.57 ,$732.00 ,$366.00 ,"$1,098.00 ",$915.00 ,$976.00 ,"$1,012.60 "
Hoopeston Regional Hlth Center,9100014,ZEISS MICROSCOPE,,,360,$24.00 ,$24.00 ,$6.72 ,$21.96 ,$16.80 ,$20.09 ,$21.96 ,$21.96 ,$21.96 ,$8.84 ,$14.40 ,$7.20 ,$21.60 ,$18.00 ,$19.20 ,$19.92
Hoopeston Regional Hlth Center,9100208,OR ROOM LEVEL 5 1ST 15 MINS,,,360,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,9100209,OR ROOM LEVEL 5 EA ADD 1 MIN,,,360,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9100015,HRHC LASER DIODE,,,360,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9100016,HRHC SIGHTPATH LASER,,,360,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9810000,EXCISION MINOR,,,361,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9450390,US RENAL CYST ASPIRATION,,50390,361,"$1,060.00 ","$1,060.00 ",$296.80 ,$969.90 ,$742.00 ,$887.22 ,$969.90 ,$969.90 ,$969.90 ,$390.61 ,$636.00 ,$318.00 ,$954.00 ,$795.00 ,$848.00 ,$879.80
Hoopeston Regional Hlth Center,9023006,THORACENTESIS/PARACENTESIS,,,361,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9026572,INSERTION PICC W/RS&I < 5 YR,,36572,361,"$1,160.00 ","$1,160.00 ",$324.80 ,"$1,061.40 ",$812.00 ,$970.92 ,"$1,061.40 ","$1,061.40 ","$1,061.40 ",$427.46 ,$696.00 ,$348.00 ,"$1,044.00 ",$870.00 ,$928.00 ,$962.80
Hoopeston Regional Hlth Center,9026573,INSERTION PICC W/RS&I 5 YR/>,,36573,361,"$2,040.00 ","$2,040.00 ",$571.20 ,"$1,866.60 ","$1,428.00 ","$1,707.48 ","$1,866.60 ","$1,866.60 ","$1,866.60 ",$751.74 ,"$1,224.00 ",$612.00 ,"$1,836.00 ","$1,530.00 ","$1,632.00 ","$1,693.20 "
Hoopeston Regional Hlth Center,9062328,DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,,62328,361,"$2,150.00 ","$2,150.00 ",$602.00 ,"$1,967.25 ","$1,505.00 ","$1,799.55 ","$1,967.25 ","$1,967.25 ","$1,967.25 ",$792.28 ,"$1,290.00 ",$645.00 ,"$1,935.00 ","$1,612.50 ","$1,720.00 ","$1,784.50 "
Hoopeston Regional Hlth Center,9062329,THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT,,62329,361,"$2,690.00 ","$2,690.00 ",$753.20 ,"$2,461.35 ","$1,883.00 ","$2,251.53 ","$2,461.35 ","$2,461.35 ","$2,461.35 ",$991.27 ,"$1,614.00 ",$807.00 ,"$2,421.00 ","$2,017.50 ","$2,152.00 ","$2,232.70 "
Hoopeston Regional Hlth Center,9100210,MODERATE SEDATION INITIAL,,,370,$4.00 ,$4.00 ,$1.12 ,$3.66 ,$2.80 ,$3.35 ,$3.66 ,$3.66 ,$3.66 ,$1.47 ,$2.40 ,$1.20 ,$3.60 ,$3.00 ,$3.20 ,$3.32
Hoopeston Regional Hlth Center,9100211,MODERATE SEDATION SUBSEQUENT,,,370,$4.00 ,$4.00 ,$1.12 ,$3.66 ,$2.80 ,$3.35 ,$3.66 ,$3.66 ,$3.66 ,$1.47 ,$2.40 ,$1.20 ,$3.60 ,$3.00 ,$3.20 ,$3.32
Hoopeston Regional Hlth Center,9386890,AUTOLOGOUS BLOOD COLL & STORG,,86890,390,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,9380017,NEONATAL BLOOD,,86999,390,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9386017,NEONATAL WHOLE BLOOD,,86999,390,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9386134,WHOLE BLOOD PER UNIT,,P9010,390,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,9380314,CRYO AHF 5 UNIT POOL,,P9012,390,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9386201,CRYOPRECIPITATE PER UNIT,,P9012,390,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,9380975,AUTOLOGOUS L-P RED BLOOD CELLS,,P9016,390,"$1,040.00 ","$1,040.00 ",$291.20 ,$951.60 ,$728.00 ,$870.48 ,$951.60 ,$951.60 ,$951.60 ,$383.24 ,$624.00 ,$312.00 ,$936.00 ,$780.00 ,$832.00 ,$863.20
Hoopeston Regional Hlth Center,9386102,LEUKO-REDUCED RED BLOOD CELLS,,P9016,390,"$1,070.00 ","$1,070.00 ",$299.60 ,$979.05 ,$749.00 ,$895.59 ,$979.05 ,$979.05 ,$979.05 ,$394.30 ,$642.00 ,$321.00 ,$963.00 ,$802.50 ,$856.00 ,$888.10
Hoopeston Regional Hlth Center,9386388,FRESH FROZEN PLASMA PER UNIT,,P9017,390,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9386395,PLATELET CONCENTRATE PER UNIT,,P9019,390,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9386426,PACKED RED BLOOD CELLS EA UNIT,,P9021,390,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9388008,AUTOLOGOUS DONOR PACKED RBC'S,,P9021,390,"$1,040.00 ","$1,040.00 ",$291.20 ,$951.60 ,$728.00 ,$870.48 ,$951.60 ,$951.60 ,$951.60 ,$383.24 ,$624.00 ,$312.00 ,$936.00 ,$780.00 ,$832.00 ,$863.20
Hoopeston Regional Hlth Center,9386036,IRRADIATION PLATELETS PER UNIT,,P9032,390,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9386112,SINGLE DONOR PLATLETS PHERESIS,,P9034,390,"$2,050.00 ","$2,050.00 ",$574.00 ,"$1,875.75 ","$1,435.00 ","$1,715.85 ","$1,875.75 ","$1,875.75 ","$1,875.75 ",$755.43 ,"$1,230.00 ",$615.00 ,"$1,845.00 ","$1,537.50 ","$1,640.00 ","$1,701.50 "
Hoopeston Regional Hlth Center,9386007,LP SINGLE DONOR PLATELETS PHER,,P9035,390,"$2,070.00 ","$2,070.00 ",$579.60 ,"$1,894.05 ","$1,449.00 ","$1,732.59 ","$1,894.05 ","$1,894.05 ","$1,894.05 ",$762.80 ,"$1,242.00 ",$621.00 ,"$1,863.00 ","$1,552.50 ","$1,656.00 ","$1,718.10 "
Hoopeston Regional Hlth Center,9386035,IRRAD SINGLE DONOR PLTLTS PHER,,P9036,390,"$2,240.00 ","$2,240.00 ",$627.20 ,"$2,049.60 ","$1,568.00 ","$1,874.88 ","$2,049.60 ","$2,049.60 ","$2,049.60 ",$825.44 ,"$1,344.00 ",$672.00 ,"$2,016.00 ","$1,680.00 ","$1,792.00 ","$1,859.20 "
Hoopeston Regional Hlth Center,9386012,LP IRRAD SNGL DONOR PLTLTS PHR,,P9037,390,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,9386034,IRRAD RED BLOOD CELLS PER UNIT,,P9038,390,$990.00 ,$990.00 ,$277.20 ,$905.85 ,$693.00 ,$828.63 ,$905.85 ,$905.85 ,$905.85 ,$364.82 ,$594.00 ,$297.00 ,$891.00 ,$742.50 ,$792.00 ,$821.70
Hoopeston Regional Hlth Center,9386033,IRRAD LEUKOCYTES REDUCED RBC'S,,P9040,390,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9386002,CRYO-POOR PLASMA,,P9044,390,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9380976,FRESH FROZEN PLASMA PER UNIT,,P9059,390,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9336430,ADMINISTER TRANSFUSION,,36430,391,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,9492228,"REMOTE IMAGE RETINA, MONITOR/MANAGE ACTIVE DISEASE",,92228,400,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9477061,DIGITAL BREAST TOMOSYNTHESIS UNILATERAL,,77061,401,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9477062,DIGITAL BREAST TOMOSYNTHESIS BILATERAL,,77062,401,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9477065,DIAGNOSTIC MAMMOGRAPHY UNILAT W/CAD,,77065,401,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,9477066,DIAGNOSTIC MAMMOGRAPHY BILAT W/CAD,,77066,401,$670.00 ,$670.00 ,$187.60 ,$613.05 ,$469.00 ,$560.79 ,$613.05 ,$613.05 ,$613.05 ,$246.90 ,$402.00 ,$201.00 ,$603.00 ,$502.50 ,$536.00 ,$556.10
Hoopeston Regional Hlth Center,8476818,FETAL BIOPHYSICAL PROFILE W/NS,,76818,402,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,9403880,US CAROTID ARTERY SCREENING,,93880,402,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9410022,US THYROID FINE NEEDLE BIOPSY,,10022,402,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9427323,US BIOPSY SOFT TISSUE KNEE OR THIGH,,27323,402,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9455700,BIOPSY PROSTATE NEEDLE,,55700,402,$93.00 ,$93.00 ,$26.04 ,$85.10 ,$65.10 ,$77.84 ,$85.10 ,$85.10 ,$85.10 ,$34.27 ,$55.80 ,$27.90 ,$83.70 ,$69.75 ,$74.40 ,$77.19
Hoopeston Regional Hlth Center,9460100,US THYROID PERCUT CORE NDL BX,,60100,402,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,9416536,US THYROID,,76536,402,$780.00 ,$780.00 ,$218.40 ,$713.70 ,$546.00 ,$652.86 ,$713.70 ,$713.70 ,$713.70 ,$287.43 ,$468.00 ,$234.00 ,$702.00 ,$585.00 ,$624.00 ,$647.40
Hoopeston Regional Hlth Center,9476536,US SOFT TISSUE NECK/HEAD,,76536,402,$780.00 ,$780.00 ,$218.40 ,$713.70 ,$546.00 ,$652.86 ,$713.70 ,$713.70 ,$713.70 ,$287.43 ,$468.00 ,$234.00 ,$702.00 ,$585.00 ,$624.00 ,$647.40
Hoopeston Regional Hlth Center,9476604,US CHEST,,76604,402,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9476700,US ABDOMEN COMPLETE,,76700,402,"$1,480.00 ","$1,480.00 ",$414.40 ,"$1,354.20 ","$1,036.00 ","$1,238.76 ","$1,354.20 ","$1,354.20 ","$1,354.20 ",$545.38 ,$888.00 ,$444.00 ,"$1,332.00 ","$1,110.00 ","$1,184.00 ","$1,228.40 "
Hoopeston Regional Hlth Center,9476705,US ABDOMEN LTD,,76705,402,$750.00 ,$750.00 ,$210.00 ,$686.25 ,$525.00 ,$627.75 ,$686.25 ,$686.25 ,$686.25 ,$276.38 ,$450.00 ,$225.00 ,$675.00 ,$562.50 ,$600.00 ,$622.50
Hoopeston Regional Hlth Center,9416775,US INFANT SACRUM,,76775,402,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9426775,US AORTA,,76775,402,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,9436775,US RENAL BILATERAL,,76775,402,$800.00 ,$800.00 ,$224.00 ,$732.00 ,$560.00 ,$669.60 ,$732.00 ,$732.00 ,$732.00 ,$294.80 ,$480.00 ,$240.00 ,$720.00 ,$600.00 ,$640.00 ,$664.00
Hoopeston Regional Hlth Center,9456775,US BLADDER,,76775,402,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,9476775,"US, RETROPERITNL ABD, LTD",,76775,402,$760.00 ,$760.00 ,$212.80 ,$695.40 ,$532.00 ,$636.12 ,$695.40 ,$695.40 ,$695.40 ,$280.06 ,$456.00 ,$228.00 ,$684.00 ,$570.00 ,$608.00 ,$630.80
Hoopeston Regional Hlth Center,9476801,US OB <14 WKS,,76801,402,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9476802,US OB ADD'L GEST <14 WKS,,76802,402,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,9476805,US OB >14WKS,,76805,402,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9476810,US OB ADD'L GEST >14 WKS,,76810,402,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9476815,US OB LIMITED,,76815,402,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9476817,US OB TRANSVAGINAL,,76817,402,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9476819,US OB BIOPHYSICAL PROFILE,,76819,402,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9476830,US PELVIC TRANSVAGINAL,,76830,402,$760.00 ,$760.00 ,$212.80 ,$695.40 ,$532.00 ,$636.12 ,$695.40 ,$695.40 ,$695.40 ,$280.06 ,$456.00 ,$228.00 ,$684.00 ,$570.00 ,$608.00 ,$630.80
Hoopeston Regional Hlth Center,9476856,US PELVIC,,76856,402,"$1,140.00 ","$1,140.00 ",$319.20 ,"$1,043.10 ",$798.00 ,$954.18 ,"$1,043.10 ","$1,043.10 ","$1,043.10 ",$420.09 ,$684.00 ,$342.00 ,"$1,026.00 ",$855.00 ,$912.00 ,$946.20
Hoopeston Regional Hlth Center,9476857,US PELVIC TRANS-VAG LTD (EG FOLICLES),,76857,402,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9476870,US SCROTUM,,76870,402,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,9476882,US EXTREMITY NON VASCULAR,,76882,402,$690.00 ,$690.00 ,$193.20 ,$631.35 ,$483.00 ,$577.53 ,$631.35 ,$631.35 ,$631.35 ,$254.27 ,$414.00 ,$207.00 ,$621.00 ,$517.50 ,$552.00 ,$572.70
Hoopeston Regional Hlth Center,9416942,US PROSTATE BIOPSY,,76942,402,$690.00 ,$690.00 ,$193.20 ,$631.35 ,$483.00 ,$577.53 ,$631.35 ,$631.35 ,$631.35 ,$254.27 ,$414.00 ,$207.00 ,$621.00 ,$517.50 ,$552.00 ,$572.70
Hoopeston Regional Hlth Center,9476942,US GUIDANCE FOR BIOPSY/NEEDLE PLACEMENT,,76942,402,$690.00 ,$690.00 ,$193.20 ,$631.35 ,$483.00 ,$577.53 ,$631.35 ,$631.35 ,$631.35 ,$254.27 ,$414.00 ,$207.00 ,$621.00 ,$517.50 ,$552.00 ,$572.70
Hoopeston Regional Hlth Center,9476999,US BACK SOFT TISSUE,,76999,402,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,9476770,ULTRASOUND RETRPRTNL COMPLETE,,76770,402,"$1,260.00 ","$1,260.00 ",$352.80 ,"$1,152.90 ",$882.00 ,"$1,054.62 ","$1,152.90 ","$1,152.90 ","$1,152.90 ",$464.31 ,$756.00 ,$378.00 ,"$1,134.00 ",$945.00 ,"$1,008.00 ","$1,045.80 "
Hoopeston Regional Hlth Center,9476998,ULTRASOUND GUIDANCE -INTRAOP,,76998,402,$405.00 ,$405.00 ,$113.40 ,$370.58 ,$283.50 ,$338.99 ,$370.58 ,$370.58 ,$370.58 ,$149.24 ,$243.00 ,$121.50 ,$364.50 ,$303.75 ,$324.00 ,$336.15
Hoopeston Regional Hlth Center,9476820,DOPPLER -FETAL UMBILICAL ARTRY,,76820,402,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9476821,DOPPLER MID CEREBRAL ARTERY,,76821,402,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,9476706,US ABD AORTA REAL TIME SCREEN STUDY AAA,,76706,402,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9476816,OB SONO FOLLOW-UP TRANSABD,,76816,402,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,9476978,ULTRASOUND TRGT DYNAMIC MICROBUBBLE 1ST LESION,,76978,402,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9476979,ULTRASOUND TRGT DYNAMIC MICROBUBBLE EA ADDL LES,,76979,402,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9476981,ULTRASOUND ELASTOGRAPHY PARENCHYMA,,76981,402,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9476982,ULTRASOUND ELASTOGRAPHY FIRST TARGET LESION,,76982,402,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9476983,ULTRASOUND ELASTOGRAPHY EA ADDL TAGET LESION,,76983,402,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9476811,HIGH RISK OB SONO SINGLE OR 1RST GEST,,76811,402,$970.00 ,$970.00 ,$271.60 ,$887.55 ,$679.00 ,$811.89 ,$887.55 ,$887.55 ,$887.55 ,$357.45 ,$582.00 ,$291.00 ,$873.00 ,$727.50 ,$776.00 ,$805.10
Hoopeston Regional Hlth Center,9476818,FETAL BIOPHYSICAL PROFILE W/NS,,76818,402,$800.00 ,$800.00 ,$224.00 ,$732.00 ,$560.00 ,$669.60 ,$732.00 ,$732.00 ,$732.00 ,$294.80 ,$480.00 ,$240.00 ,$720.00 ,$600.00 ,$640.00 ,$664.00
Hoopeston Regional Hlth Center,9476825,FETAL ECHOCARDIOGRAPHY,,76825,402,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,9403937,US GUIDANCE WITH SITE RITE,,76937,402,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9476641,US BREAST UNILATERAL COMPLETE,,76641,402,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,9476642,US BREAST UNILATERAL LIMITED,,76642,402,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9477063,SCREENING DIGITAL BREAST TOMOSYNTHESIS BILATERAL,,77063,403,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9477067,SCREENING MAMMOGRAPHY BILAT W/CAD,,77067,403,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9494640,"INHAL RX, AIRWAY OBST/DX SPUTUM INDUCT",,94640,410,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9654640,NEBULIZER TX INITIAL,,94640,410,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9651640,SUB NEBULIZER TX,,94640,410,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9654664,METER DOSE INHALER INSTRUCT,,94664,410,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9650042,PEAK FLOW TEST A & P,,94799,410,$31.00 ,$31.00 ,$8.68 ,$28.37 ,$21.70 ,$25.95 ,$28.37 ,$28.37 ,$28.37 ,$11.42 ,$18.60 ,$9.30 ,$27.90 ,$23.25 ,$24.80 ,$25.73
Hoopeston Regional Hlth Center,9094660,OSA CPAP,,94660,410,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,94640,PRESSURIZED/NONPRESSURIZED INHALATION TREATMENT,,94640,410,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9610003,CANCELLATION-24 HOURS OR LESS,,,420,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9610004,CANCELLATION-25 TO 48 HOURS,,,420,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9610006,DRIVERS EVALUATION,,,420,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,9610281,ELECTRICAL STIM FOR ULCERS,,G0281,420,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9610282,ELECTRICAL STIM FOR WOUNDS,,G0282,420,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9610283,ELECTRICAL STIMULATION,,G0283,420,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9610500,15' INDIVIDUAL SERVICE COORDIN,,T1017,420,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9610501,15' ASSESSMENT-ONSITE,,W8754,420,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9610901,BIOFEEDBACK-SPEC MUSCLE GRPS,,90901,420,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9610911,BIOFEEDBACK-PERINEAL MUSCLES,,90911,420,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9611022,LIQUID WHIRLPOOL,,97022,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9611105,SPLINT APP LNG ARM STAT 8-30',,29105,420,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9611110,15' INDIVIDUAL THERAPY-ONSITE,,97110,420,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9611125,SPLINT APP SHT ARM STAT 31-45',,29125,420,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9611126,"SPLINT APP SHT ARM DYN 8""-30""",,29126,420,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9611130,SPLINT APP FINGER STAT 8-15',,29130,420,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9611131,SPLINT APP FINGER DYN 8-30',,29131,420,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9611260,"46-60"" STRAPPING ELBOW/WRIST",,29260,420,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9611280,"31-45"" STRAPPING HAND/FINGER",,29280,420,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9611499,15' IFSP DEVELOPMENT-ONSITE,,99499,420,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9611505,"SPLINT APP LONG LEG 61""-75""",,29505,420,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9611515,"SPLINT APP SHORT LEG 61""-75""",,29515,420,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9611540,"31""-60"" ORTH CUST FT/ANKL STRP",,29540,420,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9611602,"8-30"" NONSELECTIVE DEBRIDEMENT",,97602,420,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9611750,FUNCTIONAL TESTS & MEASURES,,97750,420,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9612110,15' THERAPEUTIC EXERCISE,,97110,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9612125,SPLINT APP SHT ARM STAT 46-60',,29125,420,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9612260,"8-15"" STRAPPING ELBOW/WRIST",,29260,420,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9612280,"46-60"" STRAPPING HAND/FINGER",,29280,420,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9612505,"SPLINT APP LONG LEG 8""-30""",,29505,420,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9612515,"SPLINT APP SHORT LEG 8""-30""",,29515,420,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9612540,"8""-15"" ORTH CUST FT/ANKL STRP",,29540,420,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9613125,SPLINT APP SHT ARM STAT 8-15',,29125,420,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9613260,"31-45"" STRAPPING ELBOW/WRIST",,29260,420,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9613280,"8-15"" STRAPPING HAND/FINGER",,29280,420,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9614550,APPL SURFACE/TRNSCUT NEUROSTIM,,64550,420,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9615150,GROUP PT 31'-45',,97150,420,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9616020,DRSG/DEBRID SMALL AREA,,16020,420,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9616025,DRSG/DEBRID MEDIUM SIZE AREA,,16025,420,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9616030,DRSG/DEBRID LARGE AREA,,16030,420,$650.00 ,$650.00 ,$182.00 ,$594.75 ,$455.00 ,$544.05 ,$594.75 ,$594.75 ,$594.75 ,$239.53 ,$390.00 ,$195.00 ,$585.00 ,$487.50 ,$520.00 ,$539.50
Hoopeston Regional Hlth Center,9616150,"GROUP PT 46""-60""",,97150,420,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9617012,PELVIC & CERVICAL TRACTION,,97012,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9617016,COMPRESSION PUMP,,97016,420,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9617018,PARAFFIN,,97018,420,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9617022,DRY WHIRLPOOL,,97022,420,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9617026,"INFRARED 15""",,97026,420,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9617032,15' EMS 1:1,,97032,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9617033,15' IONTO 1:1,,97033,420,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9617034,15' CONTRAST BATH 1:1,,97034,420,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9617035,15' ULTRASOUND 1:1,,97035,420,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9617110,15' INDIVIDUAL THERAPY-OFFSITE,,97110,420,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9617112,15' NEUROMUSCULAR RE-EDUCATION,,97112,420,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9617113,15' AQUATIC THERAPY,,97113,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9617116,15' GAIT TRAINING,,97116,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9617139,THERAPEUTIC PROCEDURE,,97139,420,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9617140,15' MANUAL THERAPY,,97140,420,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9617150,15' GROUP THERAPY,,97150,420,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9617530,15' FUNCT THERAPY ACTIVITY,,97530,420,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9617533,15' SENSORY INTEGRATION,,97533,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9617535,15' ADL TRAINING,,97535,420,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9617537,15' WORK & COMMUNITY RE-ENTRY,,97537,420,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9617542,15' WHEELCHAIR MGMT TRAINING,,97542,420,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9617545,WORK CONDITIONING INITIAL 2 HR,,97545,420,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9617546,WORK CONDITIONING ADDTL HR,,97546,420,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9617597,SELECTIVE DEBRIDEMNT < 20SQ CM,,97597,420,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9617598,SELECTIVE DEBRDEMNT > 20 SQ CM,,97598,420,$475.00 ,$475.00 ,$133.00 ,$434.63 ,$332.50 ,$397.58 ,$434.63 ,$434.63 ,$434.63 ,$175.04 ,$285.00 ,$142.50 ,$427.50 ,$356.25 ,$380.00 ,$394.25
Hoopeston Regional Hlth Center,9617602,"31-60"" NONSELECTIVE DEBRIDEMNT",,97602,420,"$1,010.00 ","$1,010.00 ",$282.80 ,$924.15 ,$707.00 ,$845.37 ,$924.15 ,$924.15 ,$924.15 ,$372.19 ,$606.00 ,$303.00 ,$909.00 ,$757.50 ,$808.00 ,$838.30
Hoopeston Regional Hlth Center,9617750,FUNCTIONAL CAPACITY EVALUATION,,97750,420,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9617760,"ORTHOTIC MGMNT & TRAINING 15""",,97760,420,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9617761,PROSTHETIC TRAINING 15',,97761,420,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9618150,"GROUP PT 61""-120""",,97150,420,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9619105,SPLINT APP LNG ARM STAT 31-60',,29105,420,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9619125,SPLINT APP SHT ARM STAT 16-30',,29125,420,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9619126,"SPLINT APP SHT ARM DYN 31""-60""",,29126,420,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9619130,SPLINT APP FINGER STAT 16-30',,29130,420,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9619131,SPLINT APP FINGER DYN 31-60',,29131,420,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9619150,"GROUP PT 8""-30""",,97150,420,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9619201,ATC EVALUATION,,99201,420,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9619220,STRAPPING LOW BACK,,29799,420,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9619240,STRAPPING SHOULDER,,29240,420,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9619260,"16-30"" STRAPPING ELBOW/WRIST",,29260,420,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9619280,"16-30"" STRAPPING HAND/FINGER",,29280,420,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9619499,15' IFSP DEVELOPMENT-OFFSITE,,99499,420,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9619505,"SPLINT APP LONG LEG 31""-60""",,29505,420,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9619515,"SPLINT APP SHORT LEG 31""-60""",,29515,420,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9619520,STRAPPING HIP,,29520,420,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9619530,STRAPPING KNEE,,29530,420,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9619540,"16""-30"" ORTH CUST FT/ANKL STRP",,29540,420,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9619550,STRAPPING TOE,,29550,420,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9764550,PT TENS SET UP,,64550,420,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9717012,PT MECHANICAL TRACTION,,97012,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9717014,PT ELEC STIM UNATTENDED,,97014,420,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9717018,PT PARAFFIN BATH,,97018,420,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9711022,PT WHIRLPOOL,,97022,420,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9717022,PT STERILE WHIRLPOOL,,97022,420,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9717024,PT DIATHERMY,,97024,420,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,9717032,PT ELECT STIM MANUAL/15 MIN,,97032,420,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9717033,PT IONTOPHORESIS PER 15 MIN,,97033,420,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9717035,PT ULTRASOUND PER 15 MIN,,97035,420,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9711110,PT EXERCISE II PER 15 MIN,,97110,420,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9717110,PT EXERCISE PER 15 MIN,,97110,420,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9717112,PT NEUROMUSCULAR RE-EDUCATION PER 15 MI,,97112,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9717116,PT GAIT I PER 15 MIN,,97116,420,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9711140,PT MYOFACIAL RELEASE PER 15 MIN,,97140,420,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9712140,PT JOINT MOBILIZATION PER 15 MIN,,97140,420,$70.00 ,$70.00 ,$19.60 ,$64.05 ,$49.00 ,$58.59 ,$64.05 ,$64.05 ,$64.05 ,$25.80 ,$42.00 ,$21.00 ,$63.00 ,$52.50 ,$56.00 ,$58.10
Hoopeston Regional Hlth Center,9717140,PT MANUAL TRACTION PER 15 MIN,,97140,420,$98.00 ,$98.00 ,$27.44 ,$89.67 ,$68.60 ,$82.03 ,$89.67 ,$89.67 ,$89.67 ,$36.11 ,$58.80 ,$29.40 ,$88.20 ,$73.50 ,$78.40 ,$81.34
Hoopeston Regional Hlth Center,9717535,PT SELF CARE HOME TRAINING PER 15 MIN,,97535,420,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9717542,PT W/C MANAGEMENT PER 15 MIN,,97542,420,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9717545,PT WORK HARDENING/CONDITIONING-INIT 2HRS,,97545,420,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9717546,PT WORK HARDENING/CONDITIONING-ADD HR,,97546,420,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9717597,PT DEBRIDMENT < 20 CM,,97597,420,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9717598,PT DEBRIDMENT > 20 CM,,97598,420,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9717760,PT ORTHOTIC FIT & TRAIN CHARGE 15 MIN,,97760,420,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9717761,PT PROSTHETIC TRAINING 15 MIN,,97761,420,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,9710281,PT ESTIM WOUND,,G0281,420,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,9727032,E STIM SUPERVISED: 1 TO 1 CARE PER 15 M,,97032,420,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9714550,PT TENS SET UP,,64550,420,$51.00 ,$51.00 ,$14.28 ,$46.67 ,$35.70 ,$42.69 ,$46.67 ,$46.67 ,$46.67 ,$18.79 ,$30.60 ,$15.30 ,$45.90 ,$38.25 ,$40.80 ,$42.33
Hoopeston Regional Hlth Center,9619581,APPLY MULTI-LAY CMPRSSN; LEG (BELOW KNEE) INCL ANKLE/FT,,29581,420,$325.00 ,$325.00 ,$91.00 ,$297.38 ,$227.50 ,$272.03 ,$297.38 ,$297.38 ,$297.38 ,$119.76 ,$195.00 ,$97.50 ,$292.50 ,$243.75 ,$260.00 ,$269.75
Hoopeston Regional Hlth Center,9619584,APPLY MULTI-LAY CMPRSSN; UPPER ARM THRU HAND/FINGERS,,29584,420,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9610912,BFB TRAING W/EMG &/MANOMETRY 1ST 15 MIN CNTCT,,90912,420,$215.00 ,$215.00 ,$60.20 ,$196.73 ,$150.50 ,$179.96 ,$196.73 ,$196.73 ,$196.73 ,$79.23 ,$129.00 ,$64.50 ,$193.50 ,$161.25 ,$172.00 ,$178.45
Hoopeston Regional Hlth Center,9610913,BFB TRAING W/EMG&/MANOMETRY EA ADDL 15 MIN CNTCT,,90913,420,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9615992,"CANALITH REPOSITIONING PROCEDURE, PER DAY",,95992,420,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9797161,PT EVAL LOW COMPLEXITY,,97161,424,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9797162,PT EVAL MODERATE COMPLEXITY (0-30 MINUTES),,97162,424,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9615000,PT EVAL MODERATE COMPLEXITY (31-60 MINUTES),,97162,424,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,9615001,PT EVAL MODERATE COMPLEXITY (61-90 MINUTES),,97162,424,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,9797163,PT EVAL HIGH COMPLEXITY (0-30 MINUTES),,97163,424,$385.00 ,$385.00 ,$107.80 ,$352.28 ,$269.50 ,$322.25 ,$352.28 ,$352.28 ,$352.28 ,$141.87 ,$231.00 ,$115.50 ,$346.50 ,$288.75 ,$308.00 ,$319.55
Hoopeston Regional Hlth Center,9615002,PT EVAL HIGH COMPLEXITY (31-60 MINUTES),,97163,424,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9615003,PT EVAL HIGH COMPLEXITY (61-90 MINUTES),,97163,424,$465.00 ,$465.00 ,$130.20 ,$425.48 ,$325.50 ,$389.21 ,$425.48 ,$425.48 ,$425.48 ,$171.35 ,$279.00 ,$139.50 ,$418.50 ,$348.75 ,$372.00 ,$385.95
Hoopeston Regional Hlth Center,9797164,PT RE-EVALUATION,,97164,424,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,9629018,15' INDIVIDUAL SERVICE COORDIN,,T1017,430,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9621530,15' INDIVIDUAL THERAPY-ONSITE,,97530,430,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9622530,15' INDIVIDUAL THERAPY-OFFSITE,,97530,430,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9627150,15' GROUP THERAPY,,97150,430,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9629028,15' ASSESSMENT-ONSITE,,W8764,430,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9629029,15' ASSESSMENT-OFFSITE,,W8765,430,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9629499,15' IFSP DEVELOPMENT-ONSITE,,99499,430,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9621499,15' IFSP DEVELOPMENT-OFFSITE,,99499,430,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9620004,CANCELLATION-24 HOURS OR LESS,,,430,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9620006,CANCELLATION-25 TO 48 HOURS,,,430,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9626020,DRSG/DEBRID SMALL AREA,,16020,430,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9626025,DRSG/DEBRID MEDIUM SIZE AREA,,16025,430,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9626030,DRSG/DEBRID LARGE AREA,,16030,430,$650.00 ,$650.00 ,$182.00 ,$594.75 ,$455.00 ,$544.05 ,$594.75 ,$594.75 ,$594.75 ,$239.53 ,$390.00 ,$195.00 ,$585.00 ,$487.50 ,$520.00 ,$539.50
Hoopeston Regional Hlth Center,9621105,SPLINT APP LNG ARM STAT 31-60',,29105,430,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9621125,SPLINT APP SHT ARM STAT 16-30',,29125,430,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9621126,SPLINT APP SHT ARM DYN 31'-60',,29126,430,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9629130,SPLINT APP FINGER STAT 8-15',,29130,430,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9621131,SPLINT APP FINGER DYN 31-60',,29131,430,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9629220,STRAPPING LOW BACK,,29220,430,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9629240,STRAPPING SHOULDER,,29240,430,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9629260,"8-15"" STRAPPING ELBOW/WRIST",,29260,430,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9629280,"8-15"" STRAPPING HAND/FINGER",,29280,430,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,9622505,SPLINT APP LONG LEG 61'-75',,29505,430,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9622515,SPLINT APP SHORT LEG 61'-75',,29515,430,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9629520,STRAPPING HIP,,29520,430,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9629530,STRAPPING KNEE,,29530,430,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9629540,8'-15' ORTH CUST FT/ANKL STRP,,29540,430,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9621540,16'-30' ORTH CUST FT/ANKL STRP,,29540,430,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9622540,31'-60' ORTH CUST FT/ANKL STRP,,29540,430,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9629550,STRAPPING TOE,,29550,430,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9629105,SPLINT APP LNG ARM STAT 8-30',,29105,430,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9621505,SPLINT APP LONG LEG 31'-60',,29505,430,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9629505,SPLINT APP LONG LEG 8'-30',,29505,430,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9629515,SPLINT APP SHORT LEG 8'-30',,29515,430,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9621515,SPLINT APP SHORT LEG 31'-60',,29515,430,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9629125,SPLINT APP SHT ARM STAT 8-15',,29125,430,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9629126,SPLINT APP SHT ARM DYN 8'-30',,29126,430,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,9621130,SPLINT APP FINGER STAT 16-30',,29130,430,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9629131,SPLINT APP FINGER DYN 8-30',,29131,430,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9622125,SPLINT APP SHT ARM STAT 31-45',,29125,430,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9623125,SPLINT APP SHT ARM STAT 46-60',,29125,430,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9621260,"16-30"" STRAPPING ELBOW/WRIST",,29260,430,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9621280,"16-30"" STRAPPING HAND/FINGER",,29280,430,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,9622260,"31-45"" STRAPPING ELBOW/WRIST",,29260,430,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9622280,"31-45"" STRAPPING HAND/FINGER",,29280,430,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9623260,"46-60"" STRAPPING ELBOW/WRIST",,29260,430,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9623280,"46-60"" STRAPPING HAND/FINGER",,29280,430,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9620281,ELECTRICAL STIM FOR ULCERS,,G0281,430,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9620282,ELECTRICAL STIM FOR WOUNDS,,G0282,430,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,9620283,ELECTRICAL STIMULATION,,G0283,430,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9624550,APPL SURFACE/TRNSCUT NEUROSTIM,,64550,430,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9627022,DRY WHIRLPOOL,,97022,430,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9620901,BIOFEEDBACK-SPEC MUSCLE GRPS,,90901,430,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9620911,BIOFEEDBACK-PERINEAL MUSCLES,,90911,430,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9621022,LIQUID WHIRLPOOL,,97022,430,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9627012,PELVIC & CERVICAL TRACTION,,97012,430,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9627016,COMPRESSION PUMP,,97016,430,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,9627018,PARAFFIN,,97018,430,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9627026,"INFRARED 15""",,97026,430,$83.00 ,$83.00 ,$23.24 ,$75.95 ,$58.10 ,$69.47 ,$75.95 ,$75.95 ,$75.95 ,$30.59 ,$49.80 ,$24.90 ,$74.70 ,$62.25 ,$66.40 ,$68.89
Hoopeston Regional Hlth Center,9627032,15' EMS 1:1,,97032,430,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9627033,15' IONTO 1:1,,97033,430,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9627034,15' CONTRAST BATH 1:1,,97034,430,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9627035,15' ULTRASOUND 1:1,,97035,430,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9627110,15' THERAPEUTIC EXERCISE,,97110,430,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9627112,15' NEUROMUSCULAR RE-EDUCATION,,97112,430,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9627113,15' AQUATIC THERAPY,,97113,430,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9627116,15' GAIT TRAINING,,97116,430,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9627139,THERAPEUTIC PROCEDURE,,97139,430,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9627140,15' MANUAL THERAPY,,97140,430,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9621150,GROUP OT 8'-30',,97150,430,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9622150,GROUP OT 31'-45',,97150,430,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9623150,GROUP OT 46'-60',,97150,430,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9624150,GROUP OT 61'-120',,97150,430,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9627530,15' FUNCT THERAPY ACTIVITY,,97530,430,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9627533,15' SENSORY INTEGRATION,,97533,430,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9627535,15' ADL TRAINING,,97535,430,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9627537,15' WORK & COMMUNITY RE-ENTRY,,97537,430,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9627542,15' WHEELCHAIR MGMT TRAINING,,97542,430,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9627545,WORK CONDITIONING INITIAL 2 HR,,97545,430,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9627546,WORK CONDITIONING ADDTL HR,,97546,430,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9627597,SELECTIVE DEBRIDEMNT < 20SQ CM,,97597,430,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,9627598,SELECTIVE DEBRIDEMNT > 20SQ CM,,97598,430,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,9627602,"8-30"" NONSELECTIVE DEBRIDEMENT",,97602,430,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9621750,FUNCTIONAL TESTS & MEASURES,,97750,430,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9627750,FUNCTIONAL CAPACITY EVALUATION,,97750,430,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,9627760,"ORTHOTIC MGMNT & TRAINING 15""",,97760,430,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9627761,"PROSTHETIC TRAINING 15""",,97761,430,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9620008,DRIVERS EVALUATION,,,430,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,9621602,"31-60"" NONSELECTIVE DEBRIDEMNT",,97602,430,"$1,010.00 ","$1,010.00 ",$282.80 ,$924.15 ,$707.00 ,$845.37 ,$924.15 ,$924.15 ,$924.15 ,$372.19 ,$606.00 ,$303.00 ,$909.00 ,$757.50 ,$808.00 ,$838.30
Hoopeston Regional Hlth Center,9629201,ATC EVALUATION,,99201,430,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9729105,OT SPLINTING LONGARM SPLINT,,29105,430,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9721105,OT SPLINTING SHORTARM STATIC,,29125,430,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9729126,OT SPLINTING SHORTARM DYNAMIC,,29126,430,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9724550,OT TENS: APPLICATION OF NEUROSTIMULATOR,,64550,430,$90.00 ,$90.00 ,$25.20 ,$82.35 ,$63.00 ,$75.33 ,$82.35 ,$82.35 ,$82.35 ,$33.17 ,$54.00 ,$27.00 ,$81.00 ,$67.50 ,$72.00 ,$74.70
Hoopeston Regional Hlth Center,9723798,OT CARDIAC REHAB PER VISIT,,93798,430,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9727014,OT ELEC STIM UNATTENDED,,97014,430,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9727018,OT PARAFFIN BATH,,97018,430,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,9721022,OT STERILE WHIRLPOOL,,97022,430,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9727022,OT WHIRLPOOL,,97022,430,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9727033,OT IONTOPHORESIS PER 15 MIN,,97033,430,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9721035,OT ULTRASOUND W/EMS PER 15 MIN,,97035,430,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9727035,OT ULTRASOUND PER 15 MIN,,97035,430,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9721110,OT EXERCISE II PER 15 MIN,,97110,430,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9727110,OT THERA EXERCISE 15 MIN PER 15 MIN,,97110,430,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9721112,OT NEUROMUSCULAR RE-EDUCATION 15 MIN,,97112,430,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9727112,OT TRANSFER TRAINING PER 15 MIN,,97112,430,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9727124,OT MASSAGE 15 MIN PER 15 MIN,,97124,430,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,9721140,OT JOINT MOBILIZATION PER 15 MIN,,97140,430,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9727140,OT MANUAL EDEMA MOBILIZARION PER 15 MIN,,97140,430,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9721535,OT HOME INSTRUCTION PER 15 MIN,,97535,430,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9727535,OT ADL 15 MIN,,97535,430,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9727542,OT W/C MANAGEMENT PER 15 MIN,,97542,430,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9727545,OT WORK HARDENING 1RST 2 HOURS,,97545,430,$90.00 ,$90.00 ,$25.20 ,$82.35 ,$63.00 ,$75.33 ,$82.35 ,$82.35 ,$82.35 ,$33.17 ,$54.00 ,$27.00 ,$81.00 ,$67.50 ,$72.00 ,$74.70
Hoopeston Regional Hlth Center,9727546,WORK HARDENING ADDITIONAL HOUR,,97546,430,$65.00 ,$65.00 ,$18.20 ,$59.48 ,$45.50 ,$54.41 ,$59.48 ,$59.48 ,$59.48 ,$23.95 ,$39.00 ,$19.50 ,$58.50 ,$48.75 ,$52.00 ,$53.95
Hoopeston Regional Hlth Center,9722140,OT MYOFACIAL RELEASE PER 15 MIN,,97140,430,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9722535,OT SELF CARE/HOME MANAGEMENT PER 15 MIN,,97535,430,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9627127,THERAPEUTIC IVNTJ W/FOCUS ON COGNITIVE FUNCTION,,97127,430,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9629581,APPLY MULTI-LAY CMPRSSN; LEG (BELOW KNEE) INCL ANKLE/FT,,29581,430,$325.00 ,$325.00 ,$91.00 ,$297.38 ,$227.50 ,$272.03 ,$297.38 ,$297.38 ,$297.38 ,$119.76 ,$195.00 ,$97.50 ,$292.50 ,$243.75 ,$260.00 ,$269.75
Hoopeston Regional Hlth Center,9629584,APPLY MULTI-LAY CMPRSSN; UPPER ARM THRU HAND/FINGERS,,29584,430,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,9620912,BFB TRAING W/EMG &/MANOMETRY 1ST 15 MIN CNTCT,,90912,430,$215.00 ,$215.00 ,$60.20 ,$196.73 ,$150.50 ,$179.96 ,$196.73 ,$196.73 ,$196.73 ,$79.23 ,$129.00 ,$64.50 ,$193.50 ,$161.25 ,$172.00 ,$178.45
Hoopeston Regional Hlth Center,9620913,BFB TRAING W/EMG&/MANOMETRY EA ADDL 15 MIN CNTCT,,90913,430,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,9627129,THER IVNTJ COG FUNCJ CNTCT 1ST 15 MINUTES,,97129,430,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9627130,THER IVNTJ COG FUNCJ CNTCT EA ADDL 15 MINUTES,,97130,430,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9625992,"CANALITH REPOSITIONING PROCEDURE, PER DAY",,95992,430,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,9797165,OT EVAL LOW COMPLEXITY,,97165,434,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9797166,OT EVAL MODERATE COMPLEXITY (0-30 MINUTES),,97166,434,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9625000,OT EVAL MODERATE COMPLEXITY (31-60 MINUTES),,97166,434,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9625001,OT EVAL MODERATE COMPLEXITY (61-90 MINUTES),,97166,434,$400.00 ,$400.00 ,$112.00 ,$366.00 ,$280.00 ,$334.80 ,$366.00 ,$366.00 ,$366.00 ,$147.40 ,$240.00 ,$120.00 ,$360.00 ,$300.00 ,$320.00 ,$332.00
Hoopeston Regional Hlth Center,9797167,OT EVAL HIGH COMPLEXITY (0-30 MINUTES),,97167,434,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9625002,OT EVAL HIGH COMPLEXITY (31-60 MINUTES),,97167,434,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9625003,OT EVAL HIGH COMPLEXITY (61-90 MINUTES),,97167,434,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,9797168,OT RE-EVALUATION,,97168,434,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,9632612,8'-30' FIBEROPTIC SWALLOW EVAL,,92612,440,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9632610,8'-30' SWALLOW/ORAL FUNC EVAL,,92610,440,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,9632611,31'-45' RADIO-OPAQUE SWAL EVAL,,92611,440,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9632597,8'-60' VOICE PROSTHESIS EVAL,,92597,440,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,9633612,31'-60'FIBEROPTIC SWALLOW EVAL,,92612,440,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9631610,31'-45' SWALLOW/ORAL FUNC EVAL,,92610,440,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9633611,46'-60' RADIO-OPAQUE SWAL EVAL,,92611,440,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,9633597,61'-120' VOICE PROSTHESIS EVAL,,92597,440,$760.00 ,$760.00 ,$212.80 ,$695.40 ,$532.00 ,$636.12 ,$695.40 ,$695.40 ,$695.40 ,$280.06 ,$456.00 ,$228.00 ,$684.00 ,$570.00 ,$608.00 ,$630.80
Hoopeston Regional Hlth Center,9632626,15' SLP A/R ASSESSMENT-ONSITE,,92626,440,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9637004,15' SLPA/R IFSP DVLPMNT-ONSITE,,99499,440,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9634507,15' SLP A/R SERVICES-ONSITE,,92507,440,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9633626,15' SLP A/R ASSESSMENT-OFFSITE,,92626,440,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9637006,15' SLPA/R IFSP DVLPMT-OFFSITE,,99499,440,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9636507,15' SLP A/R SERVICES-OFFSITE,,92507,440,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9636508,15' GROUP SLP A/R SERVICES,,92508,440,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9637000,15' IFSP DEVELOPMENT-ONSITE,,99499,440,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9637002,15' IFSP DEVELOPMEMT-OFFSITE,,99499,440,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9635507,15' INDIVIDUAL THERAPY-ONSITE,,92507,440,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,9632508,15' GROUP THPY SPEECH/LANGUAGE,,92508,440,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9632579,"SP 31-60"" LARYNGOSCPY W/STRBOSCPY",,31579,440,"$1,020.00 ","$1,020.00 ",$285.60 ,$933.30 ,$714.00 ,$853.74 ,$933.30 ,$933.30 ,$933.30 ,$375.87 ,$612.00 ,$306.00 ,$918.00 ,$765.00 ,$816.00 ,$846.60
Hoopeston Regional Hlth Center,9631579,"SP 8-30"" LARYNGOSCPY W/STROBOSCPY",,31579,440,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,9632507,8-15' SPEECH TREATMENT,,92507,440,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,9631507,16-30' SPEECH TREATMENT,,92507,440,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9638507,31-45' SPEECH TREATMENT,,92507,440,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9639507,46-60' SPEECH TREATMENT,,92507,440,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,9631757,61-75' SPEECH TREATMENT,,92507,440,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9632107,76-90' SPEECH TREATMENT,,92507,440,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,9632407,"SPEECH TREATMENT > 90""",,92507,440,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,9631508,"GROUP SPEECH 8-15""",,92508,440,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,9637508,GROUP SPEECH,,92508,440,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9631658,"31-45"" GROUP SPEECH",,92508,440,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9632258,46-60' GROUP SPEECH,,92508,440,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9632458,"61-75"" GROUP SPEECH",,92508,440,$690.00 ,$690.00 ,$193.20 ,$631.35 ,$483.00 ,$577.53 ,$631.35 ,$631.35 ,$631.35 ,$254.27 ,$414.00 ,$207.00 ,$621.00 ,$517.50 ,$552.00 ,$572.70
Hoopeston Regional Hlth Center,9632658,"76-90"" GROUP SPEECH",,92508,440,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,9632858,"91-105"" GROUP SPEECH",,92508,440,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9633058,"106-120""GROUP SPEECH",,92508,440,"$1,190.00 ","$1,190.00 ",$333.20 ,"$1,088.85 ",$833.00 ,$996.03 ,"$1,088.85 ","$1,088.85 ","$1,088.85 ",$438.52 ,$714.00 ,$357.00 ,"$1,071.00 ",$892.50 ,$952.00 ,$987.70
Hoopeston Regional Hlth Center,9633458,"GROUP SPEECH > 120""",,92508,440,"$1,360.00 ","$1,360.00 ",$380.80 ,"$1,244.40 ",$952.00 ,"$1,138.32 ","$1,244.40 ","$1,244.40 ","$1,244.40 ",$501.16 ,$816.00 ,$408.00 ,"$1,224.00 ","$1,020.00 ","$1,088.00 ","$1,128.80 "
Hoopeston Regional Hlth Center,9631657,31'-60' SPEECH TREATMENT,,92507,440,$465.00 ,$465.00 ,$130.20 ,$425.48 ,$325.50 ,$389.21 ,$425.48 ,$425.48 ,$425.48 ,$171.35 ,$279.00 ,$139.50 ,$418.50 ,$348.75 ,$372.00 ,$385.95
Hoopeston Regional Hlth Center,9634508,31'-45' GROUP SPEECH,,92508,440,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9631526,31'-60' TREATMENT FOR FEEDING,,92526,440,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9639508,46'-60' GROUP SPEECH,,92508,440,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,9633526,61'-120' TREATMENT FOR FEEDING,,92526,440,"$1,120.00 ","$1,120.00 ",$313.60 ,"$1,024.80 ",$784.00 ,$937.44 ,"$1,024.80 ","$1,024.80 ","$1,024.80 ",$412.72 ,$672.00 ,$336.00 ,"$1,008.00 ",$840.00 ,$896.00 ,$929.60
Hoopeston Regional Hlth Center,9631858,61'-120' GROUP SPEECH,,92508,440,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9630507,8'-30' SPEECH TREATMENT,,92507,440,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9633508,8'-30' GROUP SPEECH,,92508,440,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9632520,8'-30' LARYNGEAL FUNCTN STUDY,,92520,440,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,9631520,31'-60' LARYNGEAL FUNCTN STUDY,,92520,440,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,9632526,8'-30' TREATMENT FOR FEEDING,,92526,440,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9633607,1ST HR EVAL SPEECH GN AC DVC,,92607,440,$410.00 ,$410.00 ,$114.80 ,$375.15 ,$287.00 ,$343.17 ,$375.15 ,$375.15 ,$375.15 ,$151.09 ,$246.00 ,$123.00 ,$369.00 ,$307.50 ,$328.00 ,$340.30
Hoopeston Regional Hlth Center,9632608,"ADL 30"" EVAL SPEECH GN AC DVC",,92608,440,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9632609,TX SVCS SPEECH GN DVC PROG&MOD,,92609,440,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9636105,15'-30' APHASIA TEST,,96105,440,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,9636125,"60"" COGNITIVE PERFORMANCE TEST",,96125,440,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9636205,31'-60' APHASIA TEST,,96105,440,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9637032,"15"" SP EMS 1:1",,97032,440,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,9637110,SP TX EXERCISE - ORAL MOTOR ACT,,97110,440,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9637112,SP NEUROMUSCULAR RE-EDUCATION,,97112,440,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9637139,THERAPEUTIC PROCEDURE,,97139,440,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,9637530,SP INSTRUCT COMP SWALLOWING TECHN,,97530,440,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9637533,SP SENSORY INTEGRATION TECHNIQUES,,97533,440,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9637535,SP 15' ADL TRAINING,,97535,440,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9637537,SP 15' WORK & COMMUNITY RE-ENTRY,,97537,440,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9637750,"SP 15"" PHYSICAL PERF TEST/MEAS.",,97750,440,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9637755,"SP 15"" ASSISTIVE TECH ASSESSMENT",,97755,440,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9721507,ST SPEECH SWALLOWING EVALUATION,,92507,440,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9722507,ST SPEECH TREATMENT INDIVIDUAL,,92507,440,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,9722526,ST DYSPHAGIA TREATMENT,,92526,440,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9722610,ST BEDSIDE DYSPHAGIA EVALUATION,,92610,440,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9726105,ST APHASIA EVALUATION PER HOUR <90 MIN,,96105,440,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9726116,COGNITIVE EVALUATION PER HR <90 MIN,,96116,440,$49.00 ,$49.00 ,$13.72 ,$44.84 ,$34.30 ,$41.01 ,$44.84 ,$44.84 ,$44.84 ,$18.06 ,$29.40 ,$14.70 ,$44.10 ,$36.75 ,$39.20 ,$40.67
Hoopeston Regional Hlth Center,9632521,SPEECH FLUENCY 8-60,,92521,440,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,9632522,SOUND PRODUCTION 8-60,,92522,440,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9632523,LANGUAGE COMP 8-60,,92523,440,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9632525,LANGUAGE COMP 60-120,,92523,440,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,9632524,Voice/Resonance,,92524,440,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,9896360,IV HYDRATION 1ST HR,,96360,450,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9896361,IV HYDRATION EA ADD'L HR,,96361,450,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9806365,ER OUTPATIENT INFUSION 1ST HR,,96365,450,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9896365,IV INFUSION 16-60 MINUTES,,96365,450,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9806366,ER OUTPATIENT INFUSION EA ADDL HR,,96366,450,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9896366,IV INFUSION EA ADD'L HR,,96366,450,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,9896367,INFUSION SEQUENTIAL,,96367,450,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9896368,CONCURRENT INFUSION,,96368,450,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,9843753,NG/OG TUBE INSET W/LAVAGE,,,450,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9810080,I&D PILONIDAL CYST,,,450,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9810120,SUBCU - SIMPLE W/INCISION,,,450,$890.00 ,$890.00 ,$249.20 ,$814.35 ,$623.00 ,$744.93 ,$814.35 ,$814.35 ,$814.35 ,$327.97 ,$534.00 ,$267.00 ,$801.00 ,$667.50 ,$712.00 ,$738.70
Hoopeston Regional Hlth Center,9810121,REMOVAL FB - COMPLEX W/INCISION,,,450,"$1,000.00 ","$1,000.00 ",$280.00 ,$915.00 ,$700.00 ,$837.00 ,$915.00 ,$915.00 ,$915.00 ,$368.50 ,$600.00 ,$300.00 ,$900.00 ,$750.00 ,$800.00 ,$830.00
Hoopeston Regional Hlth Center,9811730,REMOVAL OF TOENAIL,,,450,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9801730,REMOVAL NAIL (POST TRAUMA),,,450,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9811740,NAIL TREPHINATION,,,450,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9811760,REPAIR NAILBED,,,450,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9812020,REPAIR DEHISCENCE - SIMPLE,,,450,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,9812031,REPAIR INTERMEDIATE SCALP/TRUNK,,,450,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,9813120,REPAIR COMPLEX SCALP/EXT 1.1-2.5CM,,,450,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,9815000,BURN - 1ST DEGREE,,,450,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,9816020,TREATMENT OF 2ND DEGREE BURNS SMALL,,,450,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,9816025,DRESSING DEBRIDEMENT BURNS MEDIUM,,,450,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9816030,DRESSING DEBRIDEMENT BURNS LARGE,,,450,$650.00 ,$650.00 ,$182.00 ,$594.75 ,$455.00 ,$544.05 ,$594.75 ,$594.75 ,$594.75 ,$239.53 ,$390.00 ,$195.00 ,$585.00 ,$487.50 ,$520.00 ,$539.50
Hoopeston Regional Hlth Center,9820520,REMOVAL FB - MUSCLE/TENDONSHEATH W/INC,,,450,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9820552,TRIGGER POINT INJECTION,,,450,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9820600,"ARTHROCENTESIS /FINGER, TOE",,,450,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9820605,"ARTHROCENTESIS / ELBOW, WRIST, ANKLE",,,450,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9820610,ARTHROCENTESIS /KNEE,,,450,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,9823650,DISLOCATION CARE SHOULDER W/O ANES,,,450,$475.00 ,$475.00 ,$133.00 ,$434.63 ,$332.50 ,$397.58 ,$434.63 ,$434.63 ,$434.63 ,$175.04 ,$285.00 ,$142.50 ,$427.50 ,$356.25 ,$380.00 ,$394.25
Hoopeston Regional Hlth Center,9824600,DISLOCATION OF ELBOW (CLOSED) W/O ANES,,,450,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,9826700,DISLOCATION MP JOINT W/O ANES,,,450,$400.00 ,$400.00 ,$112.00 ,$366.00 ,$280.00 ,$334.80 ,$366.00 ,$366.00 ,$366.00 ,$147.40 ,$240.00 ,$120.00 ,$360.00 ,$300.00 ,$320.00 ,$332.00
Hoopeston Regional Hlth Center,9826770,DISLOCATION IP JOINT W/O ANES,,,450,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9827250,DISLOCATION CARE HIP W/O ANES,,,450,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9827550,DISLOCATION CARE KNEE W/O ANES,,,450,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9827840,DISLOCATION OF ANKLE (CLOSED) W/O ANES,,,450,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,9829105,SPLINT/LONG ARM,,,450,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9829125,SPLINT/SHORT ARM,,,450,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9829505,SPLINT/LONG LEG,,,450,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,9829515,SPLINT/SHORT LEG APPLICATION,,,450,$410.00 ,$410.00 ,$114.80 ,$375.15 ,$287.00 ,$343.17 ,$375.15 ,$375.15 ,$375.15 ,$151.09 ,$246.00 ,$123.00 ,$369.00 ,$307.50 ,$328.00 ,$340.30
Hoopeston Regional Hlth Center,9829705,CAST REMOVAL ARM/LEG,,,450,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9829710,CAST REMOVAL SPICA,,,450,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9829720,CAST REPAIR,,,450,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9830300,REMOVAL FB-NOSE (INTRANASAL),,,450,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9830901,EPISTAXIS CONTROL (ANTERIOR SIMPLE),,,450,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9830903,EPISTAXIS CONTROL (ANTERIOR COMPLEX),,,450,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9831500,ET INTUBATION,,,450,"$1,170.00 ","$1,170.00 ",$327.60 ,"$1,070.55 ",$819.00 ,$979.29 ,"$1,070.55 ","$1,070.55 ","$1,070.55 ",$431.15 ,$702.00 ,$351.00 ,"$1,053.00 ",$877.50 ,$936.00 ,$971.10
Hoopeston Regional Hlth Center,9831603,TRACHEOSTOMY,,,450,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,9831606,CRICOTHYROIDOTOMY,,,450,"$2,390.00 ","$2,390.00 ",$669.20 ,"$2,186.85 ","$1,673.00 ","$2,000.43 ","$2,186.85 ","$2,186.85 ","$2,186.85 ",$880.72 ,"$1,434.00 ",$717.00 ,"$2,151.00 ","$1,792.50 ","$1,912.00 ","$1,983.70 "
Hoopeston Regional Hlth Center,9832421,THORACENTESIS (PROCEDURE),,,450,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9832551,CHEST TUBE INSERTION PACK,,,450,"$1,990.00 ","$1,990.00 ",$557.20 ,"$1,820.85 ","$1,393.00 ","$1,665.63 ","$1,820.85 ","$1,820.85 ","$1,820.85 ",$733.32 ,"$1,194.00 ",$597.00 ,"$1,791.00 ","$1,492.50 ","$1,592.00 ","$1,651.70 "
Hoopeston Regional Hlth Center,9833010,PERICARDIOCENTESIS,,,450,"$1,130.00 ","$1,130.00 ",$316.40 ,"$1,033.95 ",$791.00 ,$945.81 ,"$1,033.95 ","$1,033.95 ","$1,033.95 ",$416.41 ,$678.00 ,$339.00 ,"$1,017.00 ",$847.50 ,$904.00 ,$937.90
Hoopeston Regional Hlth Center,9836680,IO NEEDLE PLACEMENT,,,450,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9840830,REPAIR MOUTH WOUNDS -2.5CM,,,450,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,9841250,REPAIR TONGUE (ANT 2/3) OR MOUTHFLOOR,,,450,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,9842809,REMOVAL FB-PHARYNX (THROAT),,,450,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,9842960,BLEEDING CONTROL SIMPLE OROPHARYNX,,,450,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,9803753,NG/OG TUBE INSET WO/LAVAGE,,,450,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9846050,I&D PERIANAL ABSCESS,,,450,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,9846320,I&D HEMORRHOID,,,450,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,9849080,PARACENTESIS PROCEDURE,,,450,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,9851701,URETHRAL CATH (STRAIGHT),,,450,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9851702,URETHRAL CATH (FOLEY),,,450,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,9851705,SUPRA-PUBIC CATHETER CHANGE,,,450,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,9856420,I&D BARTHOLINS GLAND,,,450,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9862270,LUMBAR PUNCTURE,,,450,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9865205,REMOVAL FB-EYE/CONJUNCTIVE/CORNEA,,,450,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9867938,REMOVAL FB - EYELID (IMBEDDED),,,450,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9869200,REMOVAL OF FOREIGN BODY EAR CANAL,,,450,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,9869210,REMOVAL OF FOREIGN BODY EAR IMPACTED WAX,,,450,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9892950,CPR (INCLUDING DEFIBRILLATION),,92950,450,"$1,040.00 ","$1,040.00 ",$291.20 ,$951.60 ,$728.00 ,$870.48 ,$951.60 ,$951.60 ,$951.60 ,$383.24 ,$624.00 ,$312.00 ,$936.00 ,$780.00 ,$832.00 ,$863.20
Hoopeston Regional Hlth Center,9892953,PACEMAKER - EXTERNAL,,92953,450,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,9892960,CARDIOVERSION (ER),,92960,450,"$1,010.00 ","$1,010.00 ",$282.80 ,$924.15 ,$707.00 ,$845.37 ,$924.15 ,$924.15 ,$924.15 ,$372.19 ,$606.00 ,$303.00 ,$909.00 ,$757.50 ,$808.00 ,$838.30
Hoopeston Regional Hlth Center,9892977,RETAVASE ADMINISTRATION,,92977,450,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,9896372,IM OR SUBQ INJ ADMIN,,96372,450,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9896374,IV PUSH ADMINISTRATION,,96374,450,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9896375,IV PUSH ADDITIONAL NEW DRUG,,96375,450,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9896376,IV PUSH SAME DRUG >30 MIN,,96376,450,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,9807597,"DEBRIDEMENT-SKIN,SIMPLE PARTIAL THICKNES",,97597,450,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,9897597,"DEBRIDEMENT-SKIN, FULL THICKNESS",,97597,450,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,9899281,ER LEVEL I,,99281,450,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,9899282,ER LEVEL II,,99282,450,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,9899283,ER LEVEL III,,99283,450,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9899284,ER LEVEL IV,,99284,450,"$1,210.00 ","$1,210.00 ",$338.80 ,"$1,107.15 ",$847.00 ,"$1,012.77 ","$1,107.15 ","$1,107.15 ","$1,107.15 ",$445.89 ,$726.00 ,$363.00 ,"$1,089.00 ",$907.50 ,$968.00 ,"$1,004.30 "
Hoopeston Regional Hlth Center,9899285,ER LEVEL V,,99285,450,"$1,670.00 ","$1,670.00 ",$467.60 ,"$1,528.05 ","$1,169.00 ","$1,397.79 ","$1,528.05 ","$1,528.05 ","$1,528.05 ",$615.40 ,"$1,002.00 ",$501.00 ,"$1,503.00 ","$1,252.50 ","$1,336.00 ","$1,386.10 "
Hoopeston Regional Hlth Center,9899291,CRITICAL CARE,,99291,450,"$2,310.00 ","$2,310.00 ",$646.80 ,"$2,113.65 ","$1,617.00 ","$1,933.47 ","$2,113.65 ","$2,113.65 ","$2,113.65 ",$851.24 ,"$1,386.00 ",$693.00 ,"$2,079.00 ","$1,732.50 ","$1,848.00 ","$1,917.30 "
Hoopeston Regional Hlth Center,9800061,APLIGRAF,,,450,"$8,270.00 ","$8,270.00 ","$2,315.60 ","$7,567.05 ","$5,789.00 ","$6,921.99 ","$7,567.05 ","$7,567.05 ","$7,567.05 ","$3,047.50 ","$4,962.00 ","$2,481.00 ","$7,443.00 ","$6,202.50 ","$6,616.00 ","$6,864.10 "
Hoopeston Regional Hlth Center,9800063,SPLINT-POSTERIOR,,,450,$81.00 ,$81.00 ,$22.68 ,$74.12 ,$56.70 ,$67.80 ,$74.12 ,$74.12 ,$74.12 ,$29.85 ,$48.60 ,$24.30 ,$72.90 ,$60.75 ,$64.80 ,$67.23
Hoopeston Regional Hlth Center,9800064,WALKING HEEL,,,450,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,9800065,REMOVAL FB - FOOT,,,450,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,9800066,URETHRAL CATH REMOVAL SIMPLE,,,450,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9800067,DIGITAL BLOCK,,,450,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9800068,DERMABOND/LIQIBAND CLOSURE,,,450,$82.00 ,$82.00 ,$22.96 ,$75.03 ,$57.40 ,$68.63 ,$75.03 ,$75.03 ,$75.03 ,$30.22 ,$49.20 ,$24.60 ,$73.80 ,$61.50 ,$65.60 ,$68.06
Hoopeston Regional Hlth Center,9860000,NERVE BLOCK PERIPHERAL,,,450,"$1,660.00 ","$1,660.00 ",$464.80 ,"$1,518.90 ","$1,162.00 ","$1,389.42 ","$1,518.90 ","$1,518.90 ","$1,518.90 ",$611.71 ,$996.00 ,$498.00 ,"$1,494.00 ","$1,245.00 ","$1,328.00 ","$1,377.80 "
Hoopeston Regional Hlth Center,9836556,INSRTN CNTRL LINE,,,450,"$1,340.00 ","$1,340.00 ",$375.20 ,"$1,226.10 ",$938.00 ,"$1,121.58 ","$1,226.10 ","$1,226.10 ","$1,226.10 ",$493.79 ,$804.00 ,$402.00 ,"$1,206.00 ","$1,005.00 ","$1,072.00 ","$1,112.20 "
Hoopeston Regional Hlth Center,9810001,I&D ABSCESS INTEGUMENT,,,450,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,9812001,LACERATION RPR SIMPLE,,,450,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,9896523,IRRIGATN IMPLNTD VEN ACC DVC,,96523,450,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,9810140,"I&D HEMATOMA, SEROMA, OR FLUID",,,450,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,9869209,REMOVAL IMPACTED CERUMEN IRRIGATION/LVG,,69209,450,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9800276,INTERMEDIATE REPAIR,,,450,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,9829130,SPLINT FINGER STATIC,,,450,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9864421,INTERCOSTAL NERVE BLK,,,450,"$2,100.00 ","$2,100.00 ",$588.00 ,"$1,921.50 ","$1,470.00 ","$1,757.70 ","$1,921.50 ","$1,921.50 ","$1,921.50 ",$773.85 ,"$1,260.00 ",$630.00 ,"$1,890.00 ","$1,575.00 ","$1,680.00 ","$1,743.00 "
Hoopeston Regional Hlth Center,9836572,INSERTION PICC W/RS&I < 5 YR,,36572,450,"$1,160.00 ","$1,160.00 ",$324.80 ,"$1,061.40 ",$812.00 ,$970.92 ,"$1,061.40 ","$1,061.40 ","$1,061.40 ",$427.46 ,$696.00 ,$348.00 ,"$1,044.00 ",$870.00 ,$928.00 ,$962.80
Hoopeston Regional Hlth Center,9836573,INSERTION PICC W/RS&I 5 YR/>,,36573,450,"$2,040.00 ","$2,040.00 ",$571.20 ,"$1,866.60 ","$1,428.00 ","$1,707.48 ","$1,866.60 ","$1,866.60 ","$1,866.60 ",$751.74 ,"$1,224.00 ",$612.00 ,"$1,836.00 ","$1,530.00 ","$1,632.00 ","$1,693.20 "
Hoopeston Regional Hlth Center,9851798,US BLADDER CAPACITY,,51798,450,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,9839999,BLEEDING VEIN LIGATION,,,450,"$1,260.00 ","$1,260.00 ",$352.80 ,"$1,152.90 ",$882.00 ,"$1,054.62 ","$1,152.90 ","$1,152.90 ","$1,152.90 ",$464.31 ,$756.00 ,$378.00 ,"$1,134.00 ",$945.00 ,"$1,008.00 ","$1,045.80 "
Hoopeston Regional Hlth Center,9800281,MALIG LSN EXC,,,450,"$1,390.00 ","$1,390.00 ",$389.20 ,"$1,271.85 ",$973.00 ,"$1,163.43 ","$1,271.85 ","$1,271.85 ","$1,271.85 ",$512.22 ,$834.00 ,$417.00 ,"$1,251.00 ","$1,042.50 ","$1,112.00 ","$1,153.70 "
Hoopeston Regional Hlth Center,9864405,INJ ANES AGENT GREATER OCCIPITAL NERVE,,,450,"$1,580.00 ","$1,580.00 ",$442.40 ,"$1,445.70 ","$1,106.00 ","$1,322.46 ","$1,445.70 ","$1,445.70 ","$1,445.70 ",$582.23 ,$948.00 ,$474.00 ,"$1,422.00 ","$1,185.00 ","$1,264.00 ","$1,311.40 "
Hoopeston Regional Hlth Center,9800079,CLOSED TX FX,,,450,$690.00 ,$690.00 ,$193.20 ,$631.35 ,$483.00 ,$577.53 ,$631.35 ,$631.35 ,$631.35 ,$254.27 ,$414.00 ,$207.00 ,$621.00 ,$517.50 ,$552.00 ,$572.70
Hoopeston Regional Hlth Center,9800282,DESCTRUCTION LSN,,9800282,450,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,9862328,DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,,,450,"$2,150.00 ","$2,150.00 ",$602.00 ,"$1,967.25 ","$1,505.00 ","$1,799.55 ","$1,967.25 ","$1,967.25 ","$1,967.25 ",$792.28 ,"$1,290.00 ",$645.00 ,"$1,935.00 ","$1,612.50 ","$1,720.00 ","$1,784.50 "
Hoopeston Regional Hlth Center,9862329,THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT,,,450,"$2,690.00 ","$2,690.00 ",$753.20 ,"$2,461.35 ","$1,883.00 ","$2,251.53 ","$2,461.35 ","$2,461.35 ","$2,461.35 ",$991.27 ,"$1,614.00 ",$807.00 ,"$2,421.00 ","$2,017.50 ","$2,152.00 ","$2,232.70 "
Hoopeston Regional Hlth Center,9800080,LARYNGOSCOPY,,,450,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,9800081,EXC TONGUE LSN,,,450,"$1,830.00 ","$1,830.00 ",$512.40 ,"$1,674.45 ","$1,281.00 ","$1,531.71 ","$1,674.45 ","$1,674.45 ","$1,674.45 ",$674.36 ,"$1,098.00 ",$549.00 ,"$1,647.00 ","$1,372.50 ","$1,464.00 ","$1,518.90 "
Hoopeston Regional Hlth Center,9800082,DECLOT THROM AGENT IMPL DVC/CATH,,,450,$670.00 ,$670.00 ,$187.60 ,$613.05 ,$469.00 ,$560.79 ,$613.05 ,$613.05 ,$613.05 ,$246.90 ,$402.00 ,$201.00 ,$603.00 ,$502.50 ,$536.00 ,$556.10
Hoopeston Regional Hlth Center,8809803,HC HOSPITAL OUTPT CLINIC VISIT SPECIMEN COLLECTION,,C9803,450,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9800283,CNTRL NASAL HEMM POSTERIOR INITIAL,,,450,"$1,140.00 ","$1,140.00 ",$319.20 ,"$1,043.10 ",$798.00 ,$954.18 ,"$1,043.10 ","$1,043.10 ","$1,043.10 ",$420.09 ,$684.00 ,$342.00 ,"$1,026.00 ",$855.00 ,$912.00 ,$946.20
Hoopeston Regional Hlth Center,9800284,CLSD TX PHALANGEAL SHAFT FX W/O MANIP,,,450,$720.00 ,$720.00 ,$201.60 ,$658.80 ,$504.00 ,$602.64 ,$658.80 ,$658.80 ,$658.80 ,$265.32 ,$432.00 ,$216.00 ,$648.00 ,$540.00 ,$576.00 ,$597.60
Hoopeston Regional Hlth Center,9494010,BREATHING CAPACITY,,94010,460,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9494060,EVAL BRONCHOSPASM,,94060,460,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9294060,C EVAL BRONCHOSPASM,,94060,460,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,9294010,C BREATHING CAPACITY TEST,,94010,460,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,94664,"DEMO &/OR EVAL,PT USE,AEROSOL DEVICE",,94664,460,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,94760,NONINVASV OXYGEN SATUR;SINGLE,,94760,460,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,94761,"NONINVASV OXYGEN SATUR,MULTIPLE",,94761,460,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,92567,TYMPANOMETRY,,92567,471,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,8492960,ELECTIVE CARDIO VERSION,,92960,480,$990.00 ,$990.00 ,$277.20 ,$905.85 ,$693.00 ,$828.63 ,$905.85 ,$905.85 ,$905.85 ,$364.82 ,$594.00 ,$297.00 ,$891.00 ,$742.50 ,$792.00 ,$821.70
Hoopeston Regional Hlth Center,8493303,ECHO TTE CONG CARD ANOMALIES W/O CONTRAST,,93303,480,"$1,070.00 ","$1,070.00 ",$299.60 ,$979.05 ,$749.00 ,$895.59 ,$979.05 ,$979.05 ,$979.05 ,$394.30 ,$642.00 ,$321.00 ,$963.00 ,$802.50 ,$856.00 ,$888.10
Hoopeston Regional Hlth Center,8493306,"TTE W/DOPPLER, COMPLETE W/O CONTRAST",,93306,480,"$2,310.00 ","$2,310.00 ",$646.80 ,"$2,113.65 ","$1,617.00 ","$1,933.47 ","$2,113.65 ","$2,113.65 ","$2,113.65 ",$851.24 ,"$1,386.00 ",$693.00 ,"$2,079.00 ","$1,732.50 ","$1,848.00 ","$1,917.30 "
Hoopeston Regional Hlth Center,8493308,"ECHO REAL-TIME, LIMITED W/O CONTRAST",,93308,480,"$1,230.00 ","$1,230.00 ",$344.40 ,"$1,125.45 ",$861.00 ,"$1,029.51 ","$1,125.45 ","$1,125.45 ","$1,125.45 ",$453.26 ,$738.00 ,$369.00 ,"$1,107.00 ",$922.50 ,$984.00 ,"$1,020.90 "
Hoopeston Regional Hlth Center,8493312,ECHO REAL TIME TRANSESOPH W/O CONTRAST,,93312,480,"$2,390.00 ","$2,390.00 ",$669.20 ,"$2,186.85 ","$1,673.00 ","$2,000.43 ","$2,186.85 ","$2,186.85 ","$2,186.85 ",$880.72 ,"$1,434.00 ",$717.00 ,"$2,151.00 ","$1,792.50 ","$1,912.00 ","$1,983.70 "
Hoopeston Regional Hlth Center,8493313,ECHO TEE PROBE PLACEMENT,,93313,480,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,8493314,TEE IMAGE ACQUISITION INTRP/RPRT,,93314,480,"$2,670.00 ","$2,670.00 ",$747.60 ,"$2,443.05 ","$1,869.00 ","$2,234.79 ","$2,443.05 ","$2,443.05 ","$2,443.05 ",$983.90 ,"$1,602.00 ",$801.00 ,"$2,403.00 ","$2,002.50 ","$2,136.00 ","$2,216.10 "
Hoopeston Regional Hlth Center,8493315,ECHO TEE CONG CARDIAC ANOMALY,,93315,480,"$1,610.00 ","$1,610.00 ",$450.80 ,"$1,473.15 ","$1,127.00 ","$1,347.57 ","$1,473.15 ","$1,473.15 ","$1,473.15 ",$593.29 ,$966.00 ,$483.00 ,"$1,449.00 ","$1,207.50 ","$1,288.00 ","$1,336.30 "
Hoopeston Regional Hlth Center,8493318,TEE-INTRAOP W/2D+CONT ASSMENT,,93318,480,"$1,490.00 ","$1,490.00 ",$417.20 ,"$1,363.35 ","$1,043.00 ","$1,247.13 ","$1,363.35 ","$1,363.35 ","$1,363.35 ",$549.07 ,$894.00 ,$447.00 ,"$1,341.00 ","$1,117.50 ","$1,192.00 ","$1,236.70 "
Hoopeston Regional Hlth Center,8493320,DOPPLER ECHOCARDIO GRAPHY,,93320,480,"$1,020.00 ","$1,020.00 ",$285.60 ,$933.30 ,$714.00 ,$853.74 ,$933.30 ,$933.30 ,$933.30 ,$375.87 ,$612.00 ,$306.00 ,$918.00 ,$765.00 ,$816.00 ,$846.60
Hoopeston Regional Hlth Center,8493325,DOPPLER VELOCITY MAPPING,,93325,480,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,8493350,ECHO STRESS TEST,,93350,480,$690.00 ,$690.00 ,$193.20 ,$631.35 ,$483.00 ,$577.53 ,$631.35 ,$631.35 ,$631.35 ,$254.27 ,$414.00 ,$207.00 ,$621.00 ,$517.50 ,$552.00 ,$572.70
Hoopeston Regional Hlth Center,8493351,ECHO STRESS TST W/CMPLT CV STRS TST W/O CONTRAST,,93351,480,"$1,040.00 ","$1,040.00 ",$291.20 ,$951.60 ,$728.00 ,$870.48 ,$951.60 ,$951.60 ,$951.60 ,$383.24 ,$624.00 ,$312.00 ,$936.00 ,$780.00 ,$832.00 ,$863.20
Hoopeston Regional Hlth Center,9493306,US ECHO TRANSTHORACIC,,93306,480,"$2,340.00 ","$2,340.00 ",$655.20 ,"$2,141.10 ","$1,638.00 ","$1,958.58 ","$2,141.10 ","$2,141.10 ","$2,141.10 ",$862.29 ,"$1,404.00 ",$702.00 ,"$2,106.00 ","$1,755.00 ","$1,872.00 ","$1,942.20 "
Hoopeston Regional Hlth Center,9493308,US ECHO LTD TRANSTHORACIC,,93308,480,"$1,250.00 ","$1,250.00 ",$350.00 ,"$1,143.75 ",$875.00 ,"$1,046.25 ","$1,143.75 ","$1,143.75 ","$1,143.75 ",$460.63 ,$750.00 ,$375.00 ,"$1,125.00 ",$937.50 ,"$1,000.00 ","$1,037.50 "
Hoopeston Regional Hlth Center,9493320,US DOPPLER,,93320,480,"$1,230.00 ","$1,230.00 ",$344.40 ,"$1,125.45 ",$861.00 ,"$1,029.51 ","$1,125.45 ","$1,125.45 ","$1,125.45 ",$453.26 ,$738.00 ,$369.00 ,"$1,107.00 ",$922.50 ,$984.00 ,"$1,020.90 "
Hoopeston Regional Hlth Center,9493325,US COLOR FLOW VELOCITY,,93325,480,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,9493350,US ECHO W/ STRESS,,93350,480,$840.00 ,$840.00 ,$235.20 ,$768.60 ,$588.00 ,$703.08 ,$768.60 ,$768.60 ,$768.60 ,$309.54 ,$504.00 ,$252.00 ,$756.00 ,$630.00 ,$672.00 ,$697.20
Hoopeston Regional Hlth Center,9493352,US DEFINITY CONTRAST USE,,93352,480,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,8493352,CONTRAST ADMIN,,93352,480,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,8493316,TEE PROBE PLC CONG CARDIAC ANOMALIES,,93316,480,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,9493312,ECHO TEE,,93312,480,"$2,920.00 ","$2,920.00 ",$817.60 ,"$2,671.80 ","$2,044.00 ","$2,444.04 ","$2,671.80 ","$2,671.80 ","$2,671.80 ","$1,076.02 ","$1,752.00 ",$876.00 ,"$2,628.00 ","$2,190.00 ","$2,336.00 ","$2,423.60 "
Hoopeston Regional Hlth Center,9493313,ECHO TEE PROBE PLACEMENT ONLY,,93313,480,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9493314,TEE IMAGE ACQSTN INTRP/RPRT ONLY,,93314,480,"$2,820.00 ","$2,820.00 ",$789.60 ,"$2,580.30 ","$1,974.00 ","$2,360.34 ","$2,580.30 ","$2,580.30 ","$2,580.30 ","$1,039.17 ","$1,692.00 ",$846.00 ,"$2,538.00 ","$2,115.00 ","$2,256.00 ","$2,340.60 "
Hoopeston Regional Hlth Center,9493315,ECHO TEE CNGNTL CARDIAC ANOMALIES,,93315,480,"$1,710.00 ","$1,710.00 ",$478.80 ,"$1,564.65 ","$1,197.00 ","$1,431.27 ","$1,564.65 ","$1,564.65 ","$1,564.65 ",$630.14 ,"$1,026.00 ",$513.00 ,"$1,539.00 ","$1,282.50 ","$1,368.00 ","$1,419.30 "
Hoopeston Regional Hlth Center,9493316,TEE PROBE PLC ONLY CNGNTL CARDIAC ANOMALIES,,93316,480,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9493317,TEE IMAGE ACQSTN INTRP/RPRT ONLY CNGNTL CARDIAC ANOMALIES,,93317,480,"$1,210.00 ","$1,210.00 ",$338.80 ,"$1,107.15 ",$847.00 ,"$1,012.77 ","$1,107.15 ","$1,107.15 ","$1,107.15 ",$445.89 ,$726.00 ,$363.00 ,"$1,089.00 ",$907.50 ,$968.00 ,"$1,004.30 "
Hoopeston Regional Hlth Center,9493318,TEE-INTRAOP W/2D+CONT ASSMENT,,93318,480,"$1,580.00 ","$1,580.00 ",$442.40 ,"$1,445.70 ","$1,106.00 ","$1,322.46 ","$1,445.70 ","$1,445.70 ","$1,445.70 ",$582.23 ,$948.00 ,$474.00 ,"$1,422.00 ","$1,185.00 ","$1,264.00 ","$1,311.40 "
Hoopeston Regional Hlth Center,9492960,CARDIOVERSION (RADIOLOGY),,92960,480,"$1,010.00 ","$1,010.00 ",$282.80 ,$924.15 ,$707.00 ,$845.37 ,$924.15 ,$924.15 ,$924.15 ,$372.19 ,$606.00 ,$303.00 ,$909.00 ,$757.50 ,$808.00 ,$838.30
Hoopeston Regional Hlth Center,8400008,ECHO REAL TIME TRANSESOPH W/ CONTRAST,,C8925,480,"$2,390.00 ","$2,390.00 ",$669.20 ,"$2,186.85 ","$1,673.00 ","$2,000.43 ","$2,186.85 ","$2,186.85 ","$2,186.85 ",$880.72 ,"$1,434.00 ",$717.00 ,"$2,151.00 ","$1,792.50 ","$1,912.00 ","$1,983.70 "
Hoopeston Regional Hlth Center,8400009,"TTE W/DOPPLER, COMPLETE W/ CONTRAST",,C8929,480,"$2,310.00 ","$2,310.00 ",$646.80 ,"$2,113.65 ","$1,617.00 ","$1,933.47 ","$2,113.65 ","$2,113.65 ","$2,113.65 ",$851.24 ,"$1,386.00 ",$693.00 ,"$2,079.00 ","$1,732.50 ","$1,848.00 ","$1,917.30 "
Hoopeston Regional Hlth Center,8400010,ECHO STRESS TST W/CMPLT CV STRS TST W/ CONTRAST,,C8930,480,"$1,040.00 ","$1,040.00 ",$291.20 ,$951.60 ,$728.00 ,$870.48 ,$951.60 ,$951.60 ,$951.60 ,$383.24 ,$624.00 ,$312.00 ,$936.00 ,$780.00 ,$832.00 ,$863.20
Hoopeston Regional Hlth Center,8400011,"ECHO REAL-TIME, LIMITED W/ CONTRAST",,93308,480,"$1,230.00 ","$1,230.00 ",$344.40 ,"$1,125.45 ",$861.00 ,"$1,029.51 ","$1,125.45 ","$1,125.45 ","$1,125.45 ",$453.26 ,$738.00 ,$369.00 ,"$1,107.00 ",$922.50 ,$984.00 ,"$1,020.90 "
Hoopeston Regional Hlth Center,9493351,ECHO STRESS TST W/CMPLT CV STRS TST,,93351,480,"$1,100.00 ","$1,100.00 ",$308.00 ,"$1,006.50 ",$770.00 ,$920.70 ,"$1,006.50 ","$1,006.50 ","$1,006.50 ",$405.35 ,$660.00 ,$330.00 ,$990.00 ,$825.00 ,$880.00 ,$913.00
Hoopeston Regional Hlth Center,8493017,CV STRESS TEST TRACING ONLY,,93017,482,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,9493017,US STRESS TEST,,93017,482,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,9800069,REMOVE IMPACTED CERUMEN,,,510,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9800070,OUTPATIENT WOUND DSG CHANGE MINOR,,,510,$55.00 ,$55.00 ,$15.40 ,$50.33 ,$38.50 ,$46.04 ,$50.33 ,$50.33 ,$50.33 ,$20.27 ,$33.00 ,$16.50 ,$49.50 ,$41.25 ,$44.00 ,$45.65
Hoopeston Regional Hlth Center,9800071,OUTPATIENT WOUND DSG CHANGE MAJOR,,,510,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,9299380,HRHC SPECIAL PHYSICAL,,,510,$17.00 ,$17.00 ,$4.76 ,$15.56 ,$11.90 ,$14.23 ,$15.56 ,$15.56 ,$15.56 ,$6.26 ,$10.20 ,$5.10 ,$15.30 ,$12.75 ,$13.60 ,$14.11
Hoopeston Regional Hlth Center,95146,"ANTIGEN RX SERV,INSECT,2 VENOMS",,95146,510,$96.00 ,$96.00 ,$26.88 ,$87.84 ,$67.20 ,$80.35 ,$87.84 ,$87.84 ,$87.84 ,$35.38 ,$57.60 ,$28.80 ,$86.40 ,$72.00 ,$76.80 ,$79.68
Hoopeston Regional Hlth Center,99411,"PREVENT COUNSEL,GROUP,30 MIN",,99411,510,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,96523,IRRIG IMPLANTED DRUG DELIVERY DEVICE,,96523,510,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,0500F,INITIAL PRENATAL CARE VISIT,,0500F,510,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,0502F,SUBSEQUENT PRENATAL CARE,,0502F,510,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,0503F,POSTPARTUM CARE VISIT,,0503F,510,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,12001,RESUPERF WND BODY <2.5CM,,12001,521,$620.00 ,$620.00 ,$173.60 ,$567.30 ,$434.00 ,$518.94 ,$567.30 ,$567.30 ,$567.30 ,$228.47 ,$372.00 ,$186.00 ,$558.00 ,$465.00 ,$496.00 ,$514.60
Hoopeston Regional Hlth Center,20611,ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/US,,20611,521,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,12002,RESUP NPTERF WND BODY 2.6-7.5 CM,,12002,521,$760.00 ,$760.00 ,$212.80 ,$695.40 ,$532.00 ,$636.12 ,$695.40 ,$695.40 ,$695.40 ,$280.06 ,$456.00 ,$228.00 ,$684.00 ,$570.00 ,$608.00 ,$630.80
Hoopeston Regional Hlth Center,99490,CHRONIC CARE MANAGEMENT SERVICES 1ST 20 MIN,,99490,521,$215.00 ,$215.00 ,$60.20 ,$196.73 ,$150.50 ,$179.96 ,$196.73 ,$196.73 ,$196.73 ,$79.23 ,$129.00 ,$64.50 ,$193.50 ,$161.25 ,$172.00 ,$178.45
Hoopeston Regional Hlth Center,99497,ADVANCE CARE PLANNING FIRST 30 MINS,,99497,521,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,10004,FINE NEEDLE ASPIRATION BX W/O IMG GDN EA ADDL,,10004,521,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,10005,FINE NEEDLE ASPIRATION BX W/US GDN 1ST LESION,,10005,521,$840.00 ,$840.00 ,$235.20 ,$768.60 ,$588.00 ,$703.08 ,$768.60 ,$768.60 ,$768.60 ,$309.54 ,$504.00 ,$252.00 ,$756.00 ,$630.00 ,$672.00 ,$697.20
Hoopeston Regional Hlth Center,10006,FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,,10006,521,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,10007,FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION,,10007,521,"$1,110.00 ","$1,110.00 ",$310.80 ,"$1,015.65 ",$777.00 ,$929.07 ,"$1,015.65 ","$1,015.65 ","$1,015.65 ",$409.04 ,$666.00 ,$333.00 ,$999.00 ,$832.50 ,$888.00 ,$921.30
Hoopeston Regional Hlth Center,10008,FINE NEEDLE ASPIRATION BX W/FLUOR GDN EA ADDL,,10008,521,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,10009,FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION,,10009,521,"$1,400.00 ","$1,400.00 ",$392.00 ,"$1,281.00 ",$980.00 ,"$1,171.80 ","$1,281.00 ","$1,281.00 ","$1,281.00 ",$515.90 ,$840.00 ,$420.00 ,"$1,260.00 ","$1,050.00 ","$1,120.00 ","$1,162.00 "
Hoopeston Regional Hlth Center,10010,FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL,,10010,521,$980.00 ,$980.00 ,$274.40 ,$896.70 ,$686.00 ,$820.26 ,$896.70 ,$896.70 ,$896.70 ,$361.13 ,$588.00 ,$294.00 ,$882.00 ,$735.00 ,$784.00 ,$813.40
Hoopeston Regional Hlth Center,10011,FINE NEEDLE ASPIRATION BX W/MR GDN 1ST LESION,,10011,521,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,10012,FINE NEEDLE ASPIRATION BX W/MR GDN EA ADDL,,10012,521,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,11102,TANGENTIAL BIOPSY SKIN SINGLE LESION,,11102,521,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,11103,TANGENTIAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,,11103,521,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,11104,PUNCH BIOPSY SKIN SINGLE LESION,,11104,521,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,11105,PUNCH BIOPSY SKIN EA SEP/ADDITIONAL LESION,,11105,521,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,11106,INCISIONAL BIOPSY SKIN SINGLE LESION,,11106,521,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,11107,INCISIONAL BIOPSY SKIN EA SEP/ADDITIONAL LESION,,11107,521,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,43762,PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,,43762,521,$930.00 ,$930.00 ,$260.40 ,$850.95 ,$651.00 ,$778.41 ,$850.95 ,$850.95 ,$850.95 ,$342.71 ,$558.00 ,$279.00 ,$837.00 ,$697.50 ,$744.00 ,$771.90
Hoopeston Regional Hlth Center,43763,PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC,,43763,521,"$1,730.00 ","$1,730.00 ",$484.40 ,"$1,582.95 ","$1,211.00 ","$1,448.01 ","$1,582.95 ","$1,582.95 ","$1,582.95 ",$637.51 ,"$1,038.00 ",$519.00 ,"$1,557.00 ","$1,297.50 ","$1,384.00 ","$1,435.90 "
Hoopeston Regional Hlth Center,12004,RESUPERF WND BODY 7.6-12.5 CM,,12004,521,$910.00 ,$910.00 ,$254.80 ,$832.65 ,$637.00 ,$761.67 ,$832.65 ,$832.65 ,$832.65 ,$335.34 ,$546.00 ,$273.00 ,$819.00 ,$682.50 ,$728.00 ,$755.30
Hoopeston Regional Hlth Center,12005,RESUPERF WND BODY 12.6-20 CM,,12005,521,"$1,090.00 ","$1,090.00 ",$305.20 ,$997.35 ,$763.00 ,$912.33 ,$997.35 ,$997.35 ,$997.35 ,$401.67 ,$654.00 ,$327.00 ,$981.00 ,$817.50 ,$872.00 ,$904.70
Hoopeston Regional Hlth Center,12006,RESUPERF WND BODY 20.1-30 CM,,12006,521,"$1,330.00 ","$1,330.00 ",$372.40 ,"$1,216.95 ",$931.00 ,"$1,113.21 ","$1,216.95 ","$1,216.95 ","$1,216.95 ",$490.11 ,$798.00 ,$399.00 ,"$1,197.00 ",$997.50 ,"$1,064.00 ","$1,103.90 "
Hoopeston Regional Hlth Center,12007,RESUPERF WND BODY >30 CM,,12007,521,"$1,520.00 ","$1,520.00 ",$425.60 ,"$1,390.80 ","$1,064.00 ","$1,272.24 ","$1,390.80 ","$1,390.80 ","$1,390.80 ",$560.12 ,$912.00 ,$456.00 ,"$1,368.00 ","$1,140.00 ","$1,216.00 ","$1,261.60 "
Hoopeston Regional Hlth Center,26600,CLOSED RX METACARPAL FX,,26600,521,"$1,300.00 ","$1,300.00 ",$364.00 ,"$1,189.50 ",$910.00 ,"$1,088.10 ","$1,189.50 ","$1,189.50 ","$1,189.50 ",$479.05 ,$780.00 ,$390.00 ,"$1,170.00 ",$975.00 ,"$1,040.00 ","$1,079.00 "
Hoopeston Regional Hlth Center,12011,RESUPERF WND FACE <2.5 CM,,12011,521,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,26720,CLOSE RX PROX/MID FING SHFT FX,,26720,521,$990.00 ,$990.00 ,$277.20 ,$905.85 ,$693.00 ,$828.63 ,$905.85 ,$905.85 ,$905.85 ,$364.82 ,$594.00 ,$297.00 ,$891.00 ,$742.50 ,$792.00 ,$821.70
Hoopeston Regional Hlth Center,12013,RESUPERF WND FACE 2.6-5 CM,,12013,521,$850.00 ,$850.00 ,$238.00 ,$777.75 ,$595.00 ,$711.45 ,$777.75 ,$777.75 ,$777.75 ,$313.23 ,$510.00 ,$255.00 ,$765.00 ,$637.50 ,$680.00 ,$705.50
Hoopeston Regional Hlth Center,26740,CLOSE RX FINGR ARTICULAR FX,,26740,521,"$1,360.00 ","$1,360.00 ",$380.80 ,"$1,244.40 ",$952.00 ,"$1,138.32 ","$1,244.40 ","$1,244.40 ","$1,244.40 ",$501.16 ,$816.00 ,$408.00 ,"$1,224.00 ","$1,020.00 ","$1,088.00 ","$1,128.80 "
Hoopeston Regional Hlth Center,26750,CLOSE RX DIST FINGR FX,,26750,521,$940.00 ,$940.00 ,$263.20 ,$860.10 ,$658.00 ,$786.78 ,$860.10 ,$860.10 ,$860.10 ,$346.39 ,$564.00 ,$282.00 ,$846.00 ,$705.00 ,$752.00 ,$780.20
Hoopeston Regional Hlth Center,26770,CLOSED RX IP JT DISLOCATION,,26770,521,"$1,400.00 ","$1,400.00 ",$392.00 ,"$1,281.00 ",$980.00 ,"$1,171.80 ","$1,281.00 ","$1,281.00 ","$1,281.00 ",$515.90 ,$840.00 ,$420.00 ,"$1,260.00 ","$1,050.00 ","$1,120.00 ","$1,162.00 "
Hoopeston Regional Hlth Center,12014,RESUPERF WND FACE 5.1-7.5 CM,,12014,521,"$1,020.00 ","$1,020.00 ",$285.60 ,$933.30 ,$714.00 ,$853.74 ,$933.30 ,$933.30 ,$933.30 ,$375.87 ,$612.00 ,$306.00 ,$918.00 ,$765.00 ,$816.00 ,$846.60
Hoopeston Regional Hlth Center,26775,"CLOSED RX IP JT DISLOCATION,ANESTH",,26775,521,"$1,930.00 ","$1,930.00 ",$540.40 ,"$1,765.95 ","$1,351.00 ","$1,615.41 ","$1,765.95 ","$1,765.95 ","$1,765.95 ",$711.21 ,"$1,158.00 ",$579.00 ,"$1,737.00 ","$1,447.50 ","$1,544.00 ","$1,601.90 "
Hoopeston Regional Hlth Center,12015,RESUPERF WND FACE 7.6-12.5 CM,,12015,521,"$1,250.00 ","$1,250.00 ",$350.00 ,"$1,143.75 ",$875.00 ,"$1,046.25 ","$1,143.75 ","$1,143.75 ","$1,143.75 ",$460.63 ,$750.00 ,$375.00 ,"$1,125.00 ",$937.50 ,"$1,000.00 ","$1,037.50 "
Hoopeston Regional Hlth Center,10180,"COMPLEX DRAINAGE, WOUND",,10180,521,"$1,340.00 ","$1,340.00 ",$375.20 ,"$1,226.10 ",$938.00 ,"$1,121.58 ","$1,226.10 ","$1,226.10 ","$1,226.10 ",$493.79 ,$804.00 ,$402.00 ,"$1,206.00 ","$1,005.00 ","$1,072.00 ","$1,112.20 "
Hoopeston Regional Hlth Center,12016,RESUPERF WND FACE 12.6-20 CM,,12016,521,"$1,580.00 ","$1,580.00 ",$442.40 ,"$1,445.70 ","$1,106.00 ","$1,322.46 ","$1,445.70 ","$1,445.70 ","$1,445.70 ",$582.23 ,$948.00 ,$474.00 ,"$1,422.00 ","$1,185.00 ","$1,264.00 ","$1,311.40 "
Hoopeston Regional Hlth Center,12017,RESUPERF WND FACE 20.1-30 CM,,12017,521,"$2,000.00 ","$2,000.00 ",$560.00 ,"$1,830.00 ","$1,400.00 ","$1,674.00 ","$1,830.00 ","$1,830.00 ","$1,830.00 ",$737.00 ,"$1,200.00 ",$600.00 ,"$1,800.00 ","$1,500.00 ","$1,600.00 ","$1,660.00 "
Hoopeston Regional Hlth Center,27047,EXC TUMOR SOFT TISSUE PELVIS & HIP SUBQ <3CM,,27047,521,"$3,210.00 ","$3,210.00 ",$898.80 ,"$2,937.15 ","$2,247.00 ","$2,686.77 ","$2,937.15 ","$2,937.15 ","$2,937.15 ","$1,182.89 ","$1,926.00 ",$963.00 ,"$2,889.00 ","$2,407.50 ","$2,568.00 ","$2,664.30 "
Hoopeston Regional Hlth Center,27048,EXC TUMOR SOFT TISSUE PELVIS & HIP SUBFASC <5CM,,27048,521,"$4,180.00 ","$4,180.00 ","$1,170.40 ","$3,824.70 ","$2,926.00 ","$3,498.66 ","$3,824.70 ","$3,824.70 ","$3,824.70 ","$1,540.33 ","$2,508.00 ","$1,254.00 ","$3,762.00 ","$3,135.00 ","$3,344.00 ","$3,469.40 "
Hoopeston Regional Hlth Center,27049,RAD RESECT TUMOR SOFT TISSUE PELVIS & HIP <5 CM,,27049,521,"$11,460.00 ","$11,460.00 ","$3,208.80 ","$10,485.90 ","$8,022.00 ","$9,592.02 ","$10,485.90 ","$10,485.90 ","$10,485.90 ","$4,223.01 ","$6,876.00 ","$3,438.00 ","$10,314.00 ","$8,595.00 ","$9,168.00 ","$9,511.80 "
Hoopeston Regional Hlth Center,12018,RESUPERF WND FACE >30 CM,,12018,521,"$2,580.00 ","$2,580.00 ",$722.40 ,"$2,360.70 ","$1,806.00 ","$2,159.46 ","$2,360.70 ","$2,360.70 ","$2,360.70 ",$950.73 ,"$1,548.00 ",$774.00 ,"$2,322.00 ","$1,935.00 ","$2,064.00 ","$2,141.40 "
Hoopeston Regional Hlth Center,12031,"LAYR CLOS WND TRUNK,ARM,LEG <2.5 CM",,12031,521,$800.00 ,$800.00 ,$224.00 ,$732.00 ,$560.00 ,$669.60 ,$732.00 ,$732.00 ,$732.00 ,$294.80 ,$480.00 ,$240.00 ,$720.00 ,$600.00 ,$640.00 ,$664.00
Hoopeston Regional Hlth Center,12032,"LAYR CLOS WND TRUNK,ARM,LEG 2.6-7.5 CM",,12032,521,"$1,020.00 ","$1,020.00 ",$285.60 ,$933.30 ,$714.00 ,$853.74 ,$933.30 ,$933.30 ,$933.30 ,$375.87 ,$612.00 ,$306.00 ,$918.00 ,$765.00 ,$816.00 ,$846.60
Hoopeston Regional Hlth Center,12034,"LAYR CLOS WND TRUNK,ARM,LEG 7.6-12.5 CM",,12034,521,"$1,230.00 ","$1,230.00 ",$344.40 ,"$1,125.45 ",$861.00 ,"$1,029.51 ","$1,125.45 ","$1,125.45 ","$1,125.45 ",$453.26 ,$738.00 ,$369.00 ,"$1,107.00 ",$922.50 ,$984.00 ,"$1,020.90 "
Hoopeston Regional Hlth Center,27220,CLOSED RX ACETABULAR FX,,27220,521,"$3,410.00 ","$3,410.00 ",$954.80 ,"$3,120.15 ","$2,387.00 ","$2,854.17 ","$3,120.15 ","$3,120.15 ","$3,120.15 ","$1,256.59 ","$2,046.00 ","$1,023.00 ","$3,069.00 ","$2,557.50 ","$2,728.00 ","$2,830.30 "
Hoopeston Regional Hlth Center,12035,"LAYR CLOS WND TRUNK,ARM,LEG 12.6-20 CM",,12035,521,"$1,680.00 ","$1,680.00 ",$470.40 ,"$1,537.20 ","$1,176.00 ","$1,406.16 ","$1,537.20 ","$1,537.20 ","$1,537.20 ",$619.08 ,"$1,008.00 ",$504.00 ,"$1,512.00 ","$1,260.00 ","$1,344.00 ","$1,394.40 "
Hoopeston Regional Hlth Center,27238,CLOSED RX INTER/SUBTROCH FEMUR FX,,27238,521,"$2,630.00 ","$2,630.00 ",$736.40 ,"$2,406.45 ","$1,841.00 ","$2,201.31 ","$2,406.45 ","$2,406.45 ","$2,406.45 ",$969.16 ,"$1,578.00 ",$789.00 ,"$2,367.00 ","$1,972.50 ","$2,104.00 ","$2,182.90 "
Hoopeston Regional Hlth Center,12036,"LAYR CLOS WND TRUNK,ARM,LEG 20.1-30 CM",,12036,521,"$1,950.00 ","$1,950.00 ",$546.00 ,"$1,784.25 ","$1,365.00 ","$1,632.15 ","$1,784.25 ","$1,784.25 ","$1,784.25 ",$718.58 ,"$1,170.00 ",$585.00 ,"$1,755.00 ","$1,462.50 ","$1,560.00 ","$1,618.50 "
Hoopeston Regional Hlth Center,11000,"DEBRIDEMENT, INFECTED SKIN, UP TO 10% BSA",,11000,521,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,12037,"LAYR CLOS WND TRUNK,ARM,LEG >30 CM",,12037,521,"$2,350.00 ","$2,350.00 ",$658.00 ,"$2,150.25 ","$1,645.00 ","$1,966.95 ","$2,150.25 ","$2,150.25 ","$2,150.25 ",$865.98 ,"$1,410.00 ",$705.00 ,"$2,115.00 ","$1,762.50 ","$1,880.00 ","$1,950.50 "
Hoopeston Regional Hlth Center,12041,LAYR CLOS WND REST BODY <2.5 CM,,12041,521,$970.00 ,$970.00 ,$271.60 ,$887.55 ,$679.00 ,$811.89 ,$887.55 ,$887.55 ,$887.55 ,$357.45 ,$582.00 ,$291.00 ,$873.00 ,$727.50 ,$776.00 ,$805.10
Hoopeston Regional Hlth Center,27327,EXCISION TUMOR SOFT TISSUE THIGH/KNEE SUBQ <3CM,,27327,521,"$2,570.00 ","$2,570.00 ",$719.60 ,"$2,351.55 ","$1,799.00 ","$2,151.09 ","$2,351.55 ","$2,351.55 ","$2,351.55 ",$947.05 ,"$1,542.00 ",$771.00 ,"$2,313.00 ","$1,927.50 ","$2,056.00 ","$2,133.10 "
Hoopeston Regional Hlth Center,27328,EXC TUMOR SOFT TISSUE THIGH/KNEE SUBFASC <5CM,,27328,521,"$3,580.00 ","$3,580.00 ","$1,002.40 ","$3,275.70 ","$2,506.00 ","$2,996.46 ","$3,275.70 ","$3,275.70 ","$3,275.70 ","$1,319.23 ","$2,148.00 ","$1,074.00 ","$3,222.00 ","$2,685.00 ","$2,864.00 ","$2,971.40 "
Hoopeston Regional Hlth Center,27329,RAD RESECT TUMOR SOFT TISSUE THIGH/KNEE <5CM,,27329,521,"$9,670.00 ","$9,670.00 ","$2,707.60 ","$8,848.05 ","$6,769.00 ","$8,093.79 ","$8,848.05 ","$8,848.05 ","$8,848.05 ","$3,563.40 ","$5,802.00 ","$2,901.00 ","$8,703.00 ","$7,252.50 ","$7,736.00 ","$8,026.10 "
Hoopeston Regional Hlth Center,12042,LAYR CLOS WND REST BODY 2.6-7.5 CM,,12042,521,"$1,140.00 ","$1,140.00 ",$319.20 ,"$1,043.10 ",$798.00 ,$954.18 ,"$1,043.10 ","$1,043.10 ","$1,043.10 ",$420.09 ,$684.00 ,$342.00 ,"$1,026.00 ",$855.00 ,$912.00 ,$946.20
Hoopeston Regional Hlth Center,12044,LAYR CLOS WND REST BODY 7.6-12.5 CM,,12044,521,"$1,450.00 ","$1,450.00 ",$406.00 ,"$1,326.75 ","$1,015.00 ","$1,213.65 ","$1,326.75 ","$1,326.75 ","$1,326.75 ",$534.33 ,$870.00 ,$435.00 ,"$1,305.00 ","$1,087.50 ","$1,160.00 ","$1,203.50 "
Hoopeston Regional Hlth Center,12045,LAYR CLOS WND REST BODY 12.6-20 CM,,12045,521,"$1,670.00 ","$1,670.00 ",$467.60 ,"$1,528.05 ","$1,169.00 ","$1,397.79 ","$1,528.05 ","$1,528.05 ","$1,528.05 ",$615.40 ,"$1,002.00 ",$501.00 ,"$1,503.00 ","$1,252.50 ","$1,336.00 ","$1,386.10 "
Hoopeston Regional Hlth Center,12046,LAYR CLOS WND REST BODY 20.1-30 CM,,12046,521,"$2,180.00 ","$2,180.00 ",$610.40 ,"$1,994.70 ","$1,526.00 ","$1,824.66 ","$1,994.70 ","$1,994.70 ","$1,994.70 ",$803.33 ,"$1,308.00 ",$654.00 ,"$1,962.00 ","$1,635.00 ","$1,744.00 ","$1,809.40 "
Hoopeston Regional Hlth Center,12047,LAYR CLOS WND REST BODY >30 CM,,12047,521,"$2,260.00 ","$2,260.00 ",$632.80 ,"$2,067.90 ","$1,582.00 ","$1,891.62 ","$2,067.90 ","$2,067.90 ","$2,067.90 ",$832.81 ,"$1,356.00 ",$678.00 ,"$2,034.00 ","$1,695.00 ","$1,808.00 ","$1,875.80 "
Hoopeston Regional Hlth Center,12051,"LAYR CLOS WND FACE,FACIAL <2.5 CM",,12051,521,"$1,000.00 ","$1,000.00 ",$280.00 ,$915.00 ,$700.00 ,$837.00 ,$915.00 ,$915.00 ,$915.00 ,$368.50 ,$600.00 ,$300.00 ,$900.00 ,$750.00 ,$800.00 ,$830.00
Hoopeston Regional Hlth Center,12052,"LAYR CLOS WND FACE,FACIAL 2.5-5 CM",,12052,521,"$1,240.00 ","$1,240.00 ",$347.20 ,"$1,134.60 ",$868.00 ,"$1,037.88 ","$1,134.60 ","$1,134.60 ","$1,134.60 ",$456.94 ,$744.00 ,$372.00 ,"$1,116.00 ",$930.00 ,$992.00 ,"$1,029.20 "
Hoopeston Regional Hlth Center,12053,"LAYR CLOS WND FACE,FACIAL 5.1-7.5 CM",,12053,521,"$1,520.00 ","$1,520.00 ",$425.60 ,"$1,390.80 ","$1,064.00 ","$1,272.24 ","$1,390.80 ","$1,390.80 ","$1,390.80 ",$560.12 ,$912.00 ,$456.00 ,"$1,368.00 ","$1,140.00 ","$1,216.00 ","$1,261.60 "
Hoopeston Regional Hlth Center,27500,CLOSED RX FEMUR SHAFT FX,,27500,521,"$3,530.00 ","$3,530.00 ",$988.40 ,"$3,229.95 ","$2,471.00 ","$2,954.61 ","$3,229.95 ","$3,229.95 ","$3,229.95 ","$1,300.81 ","$2,118.00 ","$1,059.00 ","$3,177.00 ","$2,647.50 ","$2,824.00 ","$2,929.90 "
Hoopeston Regional Hlth Center,27501,CLOSED RX CONDYLAR FX,,27501,521,"$3,850.00 ","$3,850.00 ","$1,078.00 ","$3,522.75 ","$2,695.00 ","$3,222.45 ","$3,522.75 ","$3,522.75 ","$3,522.75 ","$1,418.73 ","$2,310.00 ","$1,155.00 ","$3,465.00 ","$2,887.50 ","$3,080.00 ","$3,195.50 "
Hoopeston Regional Hlth Center,12054,"LAYR CLOS WND FACE,FACIAL 7.6-12.5 CM",,12054,521,"$1,800.00 ","$1,800.00 ",$504.00 ,"$1,647.00 ","$1,260.00 ","$1,506.60 ","$1,647.00 ","$1,647.00 ","$1,647.00 ",$663.30 ,"$1,080.00 ",$540.00 ,"$1,620.00 ","$1,350.00 ","$1,440.00 ","$1,494.00 "
Hoopeston Regional Hlth Center,27520,CLOSED RX PATELLA FX,,27520,521,"$1,870.00 ","$1,870.00 ",$523.60 ,"$1,711.05 ","$1,309.00 ","$1,565.19 ","$1,711.05 ","$1,711.05 ","$1,711.05 ",$689.10 ,"$1,122.00 ",$561.00 ,"$1,683.00 ","$1,402.50 ","$1,496.00 ","$1,552.10 "
Hoopeston Regional Hlth Center,27530,CLOSED RX TIBIAL PLATEAU FX,,27530,521,"$2,260.00 ","$2,260.00 ",$632.80 ,"$2,067.90 ","$1,582.00 ","$1,891.62 ","$2,067.90 ","$2,067.90 ","$2,067.90 ",$832.81 ,"$1,356.00 ",$678.00 ,"$2,034.00 ","$1,695.00 ","$1,808.00 ","$1,875.80 "
Hoopeston Regional Hlth Center,12055,"LAYR CLOS WND FACE,FACIAL 12.6-20 CM",,12055,521,"$2,250.00 ","$2,250.00 ",$630.00 ,"$2,058.75 ","$1,575.00 ","$1,883.25 ","$2,058.75 ","$2,058.75 ","$2,058.75 ",$829.13 ,"$1,350.00 ",$675.00 ,"$2,025.00 ","$1,687.50 ","$1,800.00 ","$1,867.50 "
Hoopeston Regional Hlth Center,12056,"LAYR CLOS WND FACE,FACIAL 20.1-30 CM",,12056,521,"$2,830.00 ","$2,830.00 ",$792.40 ,"$2,589.45 ","$1,981.00 ","$2,368.71 ","$2,589.45 ","$2,589.45 ","$2,589.45 ","$1,042.86 ","$1,698.00 ",$849.00 ,"$2,547.00 ","$2,122.50 ","$2,264.00 ","$2,348.90 "
Hoopeston Regional Hlth Center,12057,"LAYR CLOS WND FACE,FACIAL >30 CM",,12057,521,"$3,020.00 ","$3,020.00 ",$845.60 ,"$2,763.30 ","$2,114.00 ","$2,527.74 ","$2,763.30 ","$2,763.30 ","$2,763.30 ","$1,112.87 ","$1,812.00 ",$906.00 ,"$2,718.00 ","$2,265.00 ","$2,416.00 ","$2,506.60 "
Hoopeston Regional Hlth Center,13100,RECMPL WND TRUNK 1.1-2.5 CM,,13100,521,"$1,080.00 ","$1,080.00 ",$302.40 ,$988.20 ,$756.00 ,$903.96 ,$988.20 ,$988.20 ,$988.20 ,$397.98 ,$648.00 ,$324.00 ,$972.00 ,$810.00 ,$864.00 ,$896.40
Hoopeston Regional Hlth Center,27615,RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE <5CM,,27615,521,"$7,870.00 ","$7,870.00 ","$2,203.60 ","$7,201.05 ","$5,509.00 ","$6,587.19 ","$7,201.05 ","$7,201.05 ","$7,201.05 ","$2,900.10 ","$4,722.00 ","$2,361.00 ","$7,083.00 ","$5,902.50 ","$6,296.00 ","$6,532.10 "
Hoopeston Regional Hlth Center,27618,EXC TUMOR SOFT TISSUE LEG/ANKLE SUBQ <3CM,,27618,521,"$2,550.00 ","$2,550.00 ",$714.00 ,"$2,333.25 ","$1,785.00 ","$2,134.35 ","$2,333.25 ","$2,333.25 ","$2,333.25 ",$939.68 ,"$1,530.00 ",$765.00 ,"$2,295.00 ","$1,912.50 ","$2,040.00 ","$2,116.50 "
Hoopeston Regional Hlth Center,27619,EXC TUMOR SOFT TISSUE LEG/ANKLE SUBFASCIAL <3CM,,27619,521,"$3,470.00 ","$3,470.00 ",$971.60 ,"$3,175.05 ","$2,429.00 ","$2,904.39 ","$3,175.05 ","$3,175.05 ","$3,175.05 ","$1,278.70 ","$2,082.00 ","$1,041.00 ","$3,123.00 ","$2,602.50 ","$2,776.00 ","$2,880.10 "
Hoopeston Regional Hlth Center,13101,RECMPL WND TRUNK 2.6-7.5 CM,,13101,521,"$1,510.00 ","$1,510.00 ",$422.80 ,"$1,381.65 ","$1,057.00 ","$1,263.87 ","$1,381.65 ","$1,381.65 ","$1,381.65 ",$556.44 ,$906.00 ,$453.00 ,"$1,359.00 ","$1,132.50 ","$1,208.00 ","$1,253.30 "
Hoopeston Regional Hlth Center,13120,"RECMPL WND SCALP,EXTR 1.1-2.5 CM",,13120,521,"$1,260.00 ","$1,260.00 ",$352.80 ,"$1,152.90 ",$882.00 ,"$1,054.62 ","$1,152.90 ","$1,152.90 ","$1,152.90 ",$464.31 ,$756.00 ,$378.00 ,"$1,134.00 ",$945.00 ,"$1,008.00 ","$1,045.80 "
Hoopeston Regional Hlth Center,13121,"RECMPL WND SCALP,EXTR 2.6-7.5 CM",,13121,521,"$1,870.00 ","$1,870.00 ",$523.60 ,"$1,711.05 ","$1,309.00 ","$1,565.19 ","$1,711.05 ","$1,711.05 ","$1,711.05 ",$689.10 ,"$1,122.00 ",$561.00 ,"$1,683.00 ","$1,402.50 ","$1,496.00 ","$1,552.10 "
Hoopeston Regional Hlth Center,13131,"RECMPL WND HEAD,FAC,HAND 1.1-2.5 CM",,13131,521,"$1,580.00 ","$1,580.00 ",$442.40 ,"$1,445.70 ","$1,106.00 ","$1,322.46 ","$1,445.70 ","$1,445.70 ","$1,445.70 ",$582.23 ,$948.00 ,$474.00 ,"$1,422.00 ","$1,185.00 ","$1,264.00 ","$1,311.40 "
Hoopeston Regional Hlth Center,13132,"RECMPL WND HEAD,FAC,HAND 2.6-7.5 CM",,13132,521,"$2,400.00 ","$2,400.00 ",$672.00 ,"$2,196.00 ","$1,680.00 ","$2,008.80 ","$2,196.00 ","$2,196.00 ","$2,196.00 ",$884.40 ,"$1,440.00 ",$720.00 ,"$2,160.00 ","$1,800.00 ","$1,920.00 ","$1,992.00 "
Hoopeston Regional Hlth Center,11042,"Pr Debridement, Skin, Sub-q Tissue",,11042,521,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,27750,CLOSED RX TIBIA SHAFT FX,,27750,521,"$1,960.00 ","$1,960.00 ",$548.80 ,"$1,793.40 ","$1,372.00 ","$1,640.52 ","$1,793.40 ","$1,793.40 ","$1,793.40 ",$722.26 ,"$1,176.00 ",$588.00 ,"$1,764.00 ","$1,470.00 ","$1,568.00 ","$1,626.80 "
Hoopeston Regional Hlth Center,13150,"RECMPL WND LID,NOS,EAR <1 CM",,13150,521,$930.00 ,$930.00 ,$260.40 ,$850.95 ,$651.00 ,$778.41 ,$850.95 ,$850.95 ,$850.95 ,$342.71 ,$558.00 ,$279.00 ,$837.00 ,$697.50 ,$744.00 ,$771.90
Hoopeston Regional Hlth Center,27760,CLOSED RX MED MALLEOLUS FX,,27760,521,"$1,740.00 ","$1,740.00 ",$487.20 ,"$1,592.10 ","$1,218.00 ","$1,456.38 ","$1,592.10 ","$1,592.10 ","$1,592.10 ",$641.19 ,"$1,044.00 ",$522.00 ,"$1,566.00 ","$1,305.00 ","$1,392.00 ","$1,444.20 "
Hoopeston Regional Hlth Center,13151,"RECMPL WND LID,NOS,EAR 1.1-2.5 CM",,13151,521,"$1,900.00 ","$1,900.00 ",$532.00 ,"$1,738.50 ","$1,330.00 ","$1,590.30 ","$1,738.50 ","$1,738.50 ","$1,738.50 ",$700.15 ,"$1,140.00 ",$570.00 ,"$1,710.00 ","$1,425.00 ","$1,520.00 ","$1,577.00 "
Hoopeston Regional Hlth Center,27786,CLOSED RX DIST FIBULA FX,,27786,521,"$1,570.00 ","$1,570.00 ",$439.60 ,"$1,436.55 ","$1,099.00 ","$1,314.09 ","$1,436.55 ","$1,436.55 ","$1,436.55 ",$578.55 ,$942.00 ,$471.00 ,"$1,413.00 ","$1,177.50 ","$1,256.00 ","$1,303.10 "
Hoopeston Regional Hlth Center,13152,"RECMPL WND LID,NOS,EAR 2.5-7.5 CM",,13152,521,"$3,060.00 ","$3,060.00 ",$856.80 ,"$2,799.90 ","$2,142.00 ","$2,561.22 ","$2,799.90 ","$2,799.90 ","$2,799.90 ","$1,127.61 ","$1,836.00 ",$918.00 ,"$2,754.00 ","$2,295.00 ","$2,448.00 ","$2,539.80 "
Hoopeston Regional Hlth Center,28043,EXCISION TUMOR SOFT TISSUE FOOT/TOE SUBQ <1.5CM,,28043,521,"$1,800.00 ","$1,800.00 ",$504.00 ,"$1,647.00 ","$1,260.00 ","$1,506.60 ","$1,647.00 ","$1,647.00 ","$1,647.00 ",$663.30 ,"$1,080.00 ",$540.00 ,"$1,620.00 ","$1,350.00 ","$1,440.00 ","$1,494.00 "
Hoopeston Regional Hlth Center,28045,EXC TUMOR SOFT TISSUE FOOT/TOE SUBFASC <1.5CM,,28045,521,"$2,380.00 ","$2,380.00 ",$666.40 ,"$2,177.70 ","$1,666.00 ","$1,992.06 ","$2,177.70 ","$2,177.70 ","$2,177.70 ",$877.03 ,"$1,428.00 ",$714.00 ,"$2,142.00 ","$1,785.00 ","$1,904.00 ","$1,975.40 "
Hoopeston Regional Hlth Center,28046,RAD RESECTION TUMOR SOFT TISSUE FOOT/TOE <3CM,,28046,521,"$6,080.00 ","$6,080.00 ","$1,702.40 ","$5,563.20 ","$4,256.00 ","$5,088.96 ","$5,563.20 ","$5,563.20 ","$5,563.20 ","$2,240.48 ","$3,648.00 ","$1,824.00 ","$5,472.00 ","$4,560.00 ","$4,864.00 ","$5,046.40 "
Hoopeston Regional Hlth Center,14020,"ADJ TISS XFER SCALP,EXTREM <10 SQCM",,14020,521,"$3,210.00 ","$3,210.00 ",$898.80 ,"$2,937.15 ","$2,247.00 ","$2,686.77 ","$2,937.15 ","$2,937.15 ","$2,937.15 ","$1,182.89 ","$1,926.00 ",$963.00 ,"$2,889.00 ","$2,407.50 ","$2,568.00 ","$2,664.30 "
Hoopeston Regional Hlth Center,14021,"ADJ TISS XFER SCALP,EXTREM 10.1-30 SQCM",,14021,521,"$4,020.00 ","$4,020.00 ","$1,125.60 ","$3,678.30 ","$2,814.00 ","$3,364.74 ","$3,678.30 ","$3,678.30 ","$3,678.30 ","$1,481.37 ","$2,412.00 ","$1,206.00 ","$3,618.00 ","$3,015.00 ","$3,216.00 ","$3,336.60 "
Hoopeston Regional Hlth Center,14040,"ADJ TISS XFER HEAD,FAC,HAND <10 SQCM",,14040,521,"$3,730.00 ","$3,730.00 ","$1,044.40 ","$3,412.95 ","$2,611.00 ","$3,122.01 ","$3,412.95 ","$3,412.95 ","$3,412.95 ","$1,374.51 ","$2,238.00 ","$1,119.00 ","$3,357.00 ","$2,797.50 ","$2,984.00 ","$3,095.90 "
Hoopeston Regional Hlth Center,14041,"ADJ TISS XFER HEAD,FAC,HAND 10.1-30 SQCM",,14041,521,"$4,520.00 ","$4,520.00 ","$1,265.60 ","$4,135.80 ","$3,164.00 ","$3,783.24 ","$4,135.80 ","$4,135.80 ","$4,135.80 ","$1,665.62 ","$2,712.00 ","$1,356.00 ","$4,068.00 ","$3,390.00 ","$3,616.00 ","$3,751.60 "
Hoopeston Regional Hlth Center,11043,"PR DEBRIDEMENT, SKIN, SUB-Q TISSUE",,11043,521,"$1,300.00 ","$1,300.00 ",$364.00 ,"$1,189.50 ",$910.00 ,"$1,088.10 ","$1,189.50 ","$1,189.50 ","$1,189.50 ",$479.05 ,$780.00 ,$390.00 ,"$1,170.00 ",$975.00 ,"$1,040.00 ","$1,079.00 "
Hoopeston Regional Hlth Center,14060,"ADJ TISS XFER LID,NOS,EAR <10 SQCM",,14060,521,"$3,880.00 ","$3,880.00 ","$1,086.40 ","$3,550.20 ","$2,716.00 ","$3,247.56 ","$3,550.20 ","$3,550.20 ","$3,550.20 ","$1,429.78 ","$2,328.00 ","$1,164.00 ","$3,492.00 ","$2,910.00 ","$3,104.00 ","$3,220.40 "
Hoopeston Regional Hlth Center,14061,"ADJ TISS XFER LID,NOS,EAR 10.1-30 SQCM",,14061,521,"$5,280.00 ","$5,280.00 ","$1,478.40 ","$4,831.20 ","$3,696.00 ","$4,419.36 ","$4,831.20 ","$4,831.20 ","$4,831.20 ","$1,945.68 ","$3,168.00 ","$1,584.00 ","$4,752.00 ","$3,960.00 ","$4,224.00 ","$4,382.40 "
Hoopeston Regional Hlth Center,28400,CLOSED RX HEEL FX,,28400,521,"$1,610.00 ","$1,610.00 ",$450.80 ,"$1,473.15 ","$1,127.00 ","$1,347.57 ","$1,473.15 ","$1,473.15 ","$1,473.15 ",$593.29 ,$966.00 ,$483.00 ,"$1,449.00 ","$1,207.50 ","$1,288.00 ","$1,336.30 "
Hoopeston Regional Hlth Center,28470,CLOSED RX METATARSAL FX,,28470,521,"$1,190.00 ","$1,190.00 ",$333.20 ,"$1,088.85 ",$833.00 ,$996.03 ,"$1,088.85 ","$1,088.85 ","$1,088.85 ",$438.52 ,$714.00 ,$357.00 ,"$1,071.00 ",$892.50 ,$952.00 ,$987.70
Hoopeston Regional Hlth Center,28490,CLOSED RX BIG TOE FRACTURE,,28490,521,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,28510,CLOSED RX TOE FX,,28510,521,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,28515,"CLOSED RX TOE FX,MANIPULATN",,28515,521,$850.00 ,$850.00 ,$238.00 ,$777.75 ,$595.00 ,$711.45 ,$777.75 ,$777.75 ,$777.75 ,$313.23 ,$510.00 ,$255.00 ,$765.00 ,$637.50 ,$680.00 ,$705.50
Hoopeston Regional Hlth Center,11044,"PR DEBRIDEMENT, SKIN, SUB-Q TISSUE",,11044,521,"$2,020.00 ","$2,020.00 ",$565.60 ,"$1,848.30 ","$1,414.00 ","$1,690.74 ","$1,848.30 ","$1,848.30 ","$1,848.30 ",$744.37 ,"$1,212.00 ",$606.00 ,"$1,818.00 ","$1,515.00 ","$1,616.00 ","$1,676.60 "
Hoopeston Regional Hlth Center,28665,"CLOSED RX I-P JT,TOE DISLOC,ANESTH",,28665,521,$870.00 ,$870.00 ,$243.60 ,$796.05 ,$609.00 ,$728.19 ,$796.05 ,$796.05 ,$796.05 ,$320.60 ,$522.00 ,$261.00 ,$783.00 ,$652.50 ,$696.00 ,$722.10
Hoopeston Regional Hlth Center,15220,"FULL THICK GRFT SCALP,ARM,LEG <20SQC",,15220,521,"$4,830.00 ","$4,830.00 ","$1,352.40 ","$4,419.45 ","$3,381.00 ","$4,042.71 ","$4,419.45 ","$4,419.45 ","$4,419.45 ","$1,779.86 ","$2,898.00 ","$1,449.00 ","$4,347.00 ","$3,622.50 ","$3,864.00 ","$4,008.90 "
Hoopeston Regional Hlth Center,15221,"FULL THICK GRFT SCALP,ARM ADD 20 SQCM",,15221,521,"$1,110.00 ","$1,110.00 ",$310.80 ,"$1,015.65 ",$777.00 ,$929.07 ,"$1,015.65 ","$1,015.65 ","$1,015.65 ",$409.04 ,$666.00 ,$333.00 ,$999.00 ,$832.50 ,$888.00 ,$921.30
Hoopeston Regional Hlth Center,15240,"FULL THICK GRFT HEAD,FAC,HAND <20SQC",,15240,521,"$5,440.00 ","$5,440.00 ","$1,523.20 ","$4,977.60 ","$3,808.00 ","$4,553.28 ","$4,977.60 ","$4,977.60 ","$4,977.60 ","$2,004.64 ","$3,264.00 ","$1,632.00 ","$4,896.00 ","$4,080.00 ","$4,352.00 ","$4,515.20 "
Hoopeston Regional Hlth Center,29065,APPLY LONG ARM CAST,,29065,521,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,29075,APPLY FOREARM CAST,,29075,521,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,29085,APPLY HAND/WRIST CAST,,29085,521,$450.00 ,$450.00 ,$126.00 ,$411.75 ,$315.00 ,$376.65 ,$411.75 ,$411.75 ,$411.75 ,$165.83 ,$270.00 ,$135.00 ,$405.00 ,$337.50 ,$360.00 ,$373.50
Hoopeston Regional Hlth Center,29105,APPLY LONG ARM SPLINT,,29105,521,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,29125,"APPLY FOREARM SPLINT,STATIC",,29125,521,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,29126,"APPLY FOREARM SPLINT,DYNAMIC",,29126,521,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,29345,APPLY LONG LEG CAST,,29345,521,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,29355,"APPLY LONG LEG CAST,WALKER",,29355,521,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,15260,"FULL THICK GRFT NOS,EAR,LID <20 SQCM",,15260,521,"$5,900.00 ","$5,900.00 ","$1,652.00 ","$5,398.50 ","$4,130.00 ","$4,938.30 ","$5,398.50 ","$5,398.50 ","$5,398.50 ","$2,174.15 ","$3,540.00 ","$1,770.00 ","$5,310.00 ","$4,425.00 ","$4,720.00 ","$4,897.00 "
Hoopeston Regional Hlth Center,29405,APPLY SHORT LEG CAST,,29405,521,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,29425,"APPLY SHORT LEG CAST,WALKER",,29425,521,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,29450,APPLY OF CLUBFOOT CAST,,29450,521,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,29505,APPLY LONG LEG SPLINT,,29505,521,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,29515,APPLY LOWER LEG SPLINT,,29515,521,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,15261,"FULL THICK GRFT NOS,EAR,LID ADD 20SQ",,15261,521,"$1,900.00 ","$1,900.00 ",$532.00 ,"$1,738.50 ","$1,330.00 ","$1,590.30 ","$1,738.50 ","$1,738.50 ","$1,738.50 ",$700.15 ,"$1,140.00 ",$570.00 ,"$1,710.00 ","$1,425.00 ","$1,520.00 ","$1,577.00 "
Hoopeston Regional Hlth Center,29540,STRAPPING; ANKLE &/OR FOOT,,29540,521,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,29550,STRAPPING OF TOES,,29550,521,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,29580,STRAPPING UNNA BOOT,,29580,521,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,11100,BIOPSY OF SKIN LESION,,11100,521,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,30300,REMOVE NASAL FOREIGN BODY,,30300,521,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,30901,"CTRL NOSEBLEED,ANTER,SIMPLE",,30901,521,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,31000,IRRIGATION MAXILLARY SINUS,,31000,521,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,31500,INSERT EMERGENCY ENDOTRACH AIRWAY,,31500,521,"$1,100.00 ","$1,100.00 ",$308.00 ,"$1,006.50 ",$770.00 ,$920.70 ,"$1,006.50 ","$1,006.50 ","$1,006.50 ",$405.35 ,$660.00 ,$330.00 ,$990.00 ,$825.00 ,$880.00 ,$913.00
Hoopeston Regional Hlth Center,31603,"TRACHEOSTOMY,EMERG,XTRACH",,31603,521,"$2,830.00 ","$2,830.00 ",$792.40 ,"$2,589.45 ","$1,981.00 ","$2,368.71 ","$2,589.45 ","$2,589.45 ","$2,589.45 ","$1,042.86 ","$1,698.00 ",$849.00 ,"$2,547.00 ","$2,122.50 ","$2,264.00 ","$2,348.90 "
Hoopeston Regional Hlth Center,31605,"TRACHEOSTOMY,EMERG,CRICOTHYROID",,31605,521,"$2,260.00 ","$2,260.00 ",$632.80 ,"$2,067.90 ","$1,582.00 ","$1,891.62 ","$2,067.90 ","$2,067.90 ","$2,067.90 ",$832.81 ,"$1,356.00 ",$678.00 ,"$2,034.00 ","$1,695.00 ","$1,808.00 ","$1,875.80 "
Hoopeston Regional Hlth Center,31646,BRONCHOSCOPY W/THER ASPIR TRACHBRNCL TREE SBSQ,,31646,521,"$1,940.00 ","$1,940.00 ",$543.20 ,"$1,775.10 ","$1,358.00 ","$1,623.78 ","$1,775.10 ","$1,775.10 ","$1,775.10 ",$714.89 ,"$1,164.00 ",$582.00 ,"$1,746.00 ","$1,455.00 ","$1,552.00 ","$1,610.20 "
Hoopeston Regional Hlth Center,11200,"REMOVAL OF SKIN TAGS, UP TO 15",,11200,521,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,11201,"REMOVAL OF SKIN TAGS, EACH ADD 10",,11201,521,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,11300,"SHAV SKIN LES < 0.5 CM TRUNK,ARM,LEG",,11300,521,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,15852,"DRESSING CHANGE,NOT FOR BURN",,15852,521,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,11301,"SHAV SKIN LES 0.6-1.0 CM TRUNK,ARM,LEG",,11301,521,$375.00 ,$375.00 ,$105.00 ,$343.13 ,$262.50 ,$313.88 ,$343.13 ,$343.13 ,$343.13 ,$138.19 ,$225.00 ,$112.50 ,$337.50 ,$281.25 ,$300.00 ,$311.25
Hoopeston Regional Hlth Center,36400,VNPNXR <3 YEARS PHY/QHP SKILL FEMRAL/JUGLAR VEIN,,36400,521,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,11302,"SHAV SKIN LES 1.1-2.0 CM TRUNK,ARM,LEG",,11302,521,$435.00 ,$435.00 ,$121.80 ,$398.03 ,$304.50 ,$364.10 ,$398.03 ,$398.03 ,$398.03 ,$160.30 ,$261.00 ,$130.50 ,$391.50 ,$326.25 ,$348.00 ,$361.05
Hoopeston Regional Hlth Center,36410,VNPNXR 3 YEARS/> PHYS/QHP SKILL,,36410,521,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,36430,BLOOD TRANSFUSION SERVICE,,36430,521,$435.00 ,$435.00 ,$121.80 ,$398.03 ,$304.50 ,$364.10 ,$398.03 ,$398.03 ,$398.03 ,$160.30 ,$261.00 ,$130.50 ,$391.50 ,$326.25 ,$348.00 ,$361.05
Hoopeston Regional Hlth Center,36620,"INSERT CATH,ART,PERCUT,SHORTTERM",,36620,521,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,39000,"Pr Mediastinotomy, Cerv Approach",,39000,521,"$4,280.00 ","$4,280.00 ","$1,198.40 ","$3,916.20 ","$2,996.00 ","$3,582.36 ","$3,916.20 ","$3,916.20 ","$3,916.20 ","$1,577.18 ","$2,568.00 ","$1,284.00 ","$3,852.00 ","$3,210.00 ","$3,424.00 ","$3,552.40 "
Hoopeston Regional Hlth Center,11303,"SHAV SKIN LES >2.1 CM TRUNK,ARM,LEG",,11303,521,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,16000,INITIAL RX BURN(S) 1ST DEGREE,,16000,521,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,16020,DRESS/DEBRID SMALL BURN NO ANES,,16020,521,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,16025,DRESS/DEBRID MED BURN NO ANESTH,,16025,521,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,41010,INCISION OF TONGUE FOLD,,41010,521,$980.00 ,$980.00 ,$274.40 ,$896.70 ,$686.00 ,$820.26 ,$896.70 ,$896.70 ,$896.70 ,$361.13 ,$588.00 ,$294.00 ,$882.00 ,$735.00 ,$784.00 ,$813.40
Hoopeston Regional Hlth Center,16030,DRESS/DEBRID LARGE BURN NO ANESTH,,16030,521,"$1,050.00 ","$1,050.00 ",$294.00 ,$960.75 ,$735.00 ,$878.85 ,$960.75 ,$960.75 ,$960.75 ,$386.93 ,$630.00 ,$315.00 ,$945.00 ,$787.50 ,$840.00 ,$871.50
Hoopeston Regional Hlth Center,17000,DESTRUCTION PREMALIGNANT LSN FIRST,,17000,521,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,17106,DESTRUC CUT/VASC <10 SQCM,,17106,521,"$1,440.00 ","$1,440.00 ",$403.20 ,"$1,317.60 ","$1,008.00 ","$1,205.28 ","$1,317.60 ","$1,317.60 ","$1,317.60 ",$530.64 ,$864.00 ,$432.00 ,"$1,296.00 ","$1,080.00 ","$1,152.00 ","$1,195.20 "
Hoopeston Regional Hlth Center,17107,DESTRUC CUT/VASC 10-50 SQCM,,17107,521,"$2,570.00 ","$2,570.00 ",$719.60 ,"$2,351.55 ","$1,799.00 ","$2,151.09 ","$2,351.55 ","$2,351.55 ","$2,351.55 ",$947.05 ,"$1,542.00 ",$771.00 ,"$2,313.00 ","$1,927.50 ","$2,056.00 ","$2,133.10 "
Hoopeston Regional Hlth Center,17108,DESTRUC CUT/VASC >50 SQCM,,17108,521,"$3,800.00 ","$3,800.00 ","$1,064.00 ","$3,477.00 ","$2,660.00 ","$3,180.60 ","$3,477.00 ","$3,477.00 ","$3,477.00 ","$1,400.30 ","$2,280.00 ","$1,140.00 ","$3,420.00 ","$2,850.00 ","$3,040.00 ","$3,154.00 "
Hoopeston Regional Hlth Center,11305,SHAV SKIN LES <0.5 CM REMAINDER BODY,,11305,521,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,17110,DESTRUCTION BENIGN LESIONS UP TO 14,,17110,521,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,17250,CHEMICAL CAUTERIZATION OF GRANULATION TISSUE,,17250,521,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,17260,"DESTR MALIG TRUNK,EXTREM <0.6 CM",,17260,521,$400.00 ,$400.00 ,$112.00 ,$366.00 ,$280.00 ,$334.80 ,$366.00 ,$366.00 ,$366.00 ,$147.40 ,$240.00 ,$120.00 ,$360.00 ,$300.00 ,$320.00 ,$332.00
Hoopeston Regional Hlth Center,17261,"DESTR MALIG TRUNK,EXTREM 0.6-1 CM",,17261,521,$475.00 ,$475.00 ,$133.00 ,$434.63 ,$332.50 ,$397.58 ,$434.63 ,$434.63 ,$434.63 ,$175.04 ,$285.00 ,$142.50 ,$427.50 ,$356.25 ,$380.00 ,$394.25
Hoopeston Regional Hlth Center,17262,"DESTR MALIG TRUNK,EXTREM 1.1-2 CM",,17262,521,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,17263,"DESTR MALIG TRUNK,EXTREM 2.1-3 CM",,17263,521,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,17264,"DESTR MALIG TRUNK,EXTREM 3.1-4 CM",,17264,521,$820.00 ,$820.00 ,$229.60 ,$750.30 ,$574.00 ,$686.34 ,$750.30 ,$750.30 ,$750.30 ,$302.17 ,$492.00 ,$246.00 ,$738.00 ,$615.00 ,$656.00 ,$680.60
Hoopeston Regional Hlth Center,17266,"DESTR MALIG TRUNK,EXTREM >4.0 CM",,17266,521,$980.00 ,$980.00 ,$274.40 ,$896.70 ,$686.00 ,$820.26 ,$896.70 ,$896.70 ,$896.70 ,$361.13 ,$588.00 ,$294.00 ,$882.00 ,$735.00 ,$784.00 ,$813.40
Hoopeston Regional Hlth Center,17270,"DESTR MALIG SCAL,NCK,HAND <0.6 CM",,17270,521,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,17271,"DESTR MALIG SCAL,NCK,HAND 0.6-1 CM",,17271,521,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,11306,SHAV SKIN LES 0.6-1.0 CM REMAINDER BODY,,11306,521,$385.00 ,$385.00 ,$107.80 ,$352.28 ,$269.50 ,$322.25 ,$352.28 ,$352.28 ,$352.28 ,$141.87 ,$231.00 ,$115.50 ,$346.50 ,$288.75 ,$308.00 ,$319.55
Hoopeston Regional Hlth Center,43235,ESOPHAGOGASTRODUODENOSCOPY TRANSORAL DIAGNOSTIC,,43235,521,"$1,510.00 ","$1,510.00 ",$422.80 ,"$1,381.65 ","$1,057.00 ","$1,263.87 ","$1,381.65 ","$1,381.65 ","$1,381.65 ",$556.44 ,$906.00 ,$453.00 ,"$1,359.00 ","$1,132.50 ","$1,208.00 ","$1,253.30 "
Hoopeston Regional Hlth Center,43239,EDG TRANSORAL BIOPSY SINGLE/MULTIPLE,,43239,521,"$2,230.00 ","$2,230.00 ",$624.40 ,"$2,040.45 ","$1,561.00 ","$1,866.51 ","$2,040.45 ","$2,040.45 ","$2,040.45 ",$821.76 ,"$1,338.00 ",$669.00 ,"$2,007.00 ","$1,672.50 ","$1,784.00 ","$1,850.90 "
Hoopeston Regional Hlth Center,17272,"DESTR MALIG SCAL,NCK,HAND 1.1-2 CM",,17272,521,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,43249,EDG BALLOON DILATION ESOPHAGUS <30 MM DIAM,,43249,521,"$2,230.00 ","$2,230.00 ",$624.40 ,"$2,040.45 ","$1,561.00 ","$1,866.51 ","$2,040.45 ","$2,040.45 ","$2,040.45 ",$821.76 ,"$1,338.00 ",$669.00 ,"$2,007.00 ","$1,672.50 ","$1,784.00 ","$1,850.90 "
Hoopeston Regional Hlth Center,17273,"DESTR MALIG SCAL,NCK,HAND 2.1-3 CM",,17273,521,$830.00 ,$830.00 ,$232.40 ,$759.45 ,$581.00 ,$694.71 ,$759.45 ,$759.45 ,$759.45 ,$305.86 ,$498.00 ,$249.00 ,$747.00 ,$622.50 ,$664.00 ,$688.90
Hoopeston Regional Hlth Center,17274,"DESTR MALIG SCAL,NCK,HAND 3.1-4 CM",,17274,521,$930.00 ,$930.00 ,$260.40 ,$850.95 ,$651.00 ,$778.41 ,$850.95 ,$850.95 ,$850.95 ,$342.71 ,$558.00 ,$279.00 ,$837.00 ,$697.50 ,$744.00 ,$771.90
Hoopeston Regional Hlth Center,17276,"DESTR MALIG SCAL,NCK,HAND >4 CM",,17276,521,"$1,090.00 ","$1,090.00 ",$305.20 ,$997.35 ,$763.00 ,$912.33 ,$997.35 ,$997.35 ,$997.35 ,$401.67 ,$654.00 ,$327.00 ,$981.00 ,$817.50 ,$872.00 ,$904.70
Hoopeston Regional Hlth Center,17280,"DESTR MALIG FACE,NOSE,LIP <0.6 CM",,17280,521,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,17281,"DESTR MALIG FACE,NOSE,LIP 0.6-1 CM",,17281,521,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,17282,"DESTR MALIG FACE,NOSE,LIP 1.1-2 CM",,17282,521,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,17284,"DESTR MALIG FACE,NOSE,LIP 3.1-4 CM",,17284,521,"$1,060.00 ","$1,060.00 ",$296.80 ,$969.90 ,$742.00 ,$887.22 ,$969.90 ,$969.90 ,$969.90 ,$390.61 ,$636.00 ,$318.00 ,$954.00 ,$795.00 ,$848.00 ,$879.80
Hoopeston Regional Hlth Center,17286,"DESTR MALIG FACE,NOSE,LIP >4 CM",,17286,521,"$1,330.00 ","$1,330.00 ",$372.40 ,"$1,216.95 ",$931.00 ,"$1,113.21 ","$1,216.95 ","$1,216.95 ","$1,216.95 ",$490.11 ,$798.00 ,$399.00 ,"$1,197.00 ",$997.50 ,"$1,064.00 ","$1,103.90 "
Hoopeston Regional Hlth Center,11307,SHAV SKIN LES 1.1-2.0 CM REMAINDER BODY,,11307,521,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,17340,CRYOTHERAPY ACNE,,17340,521,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,19000,PUNC/ASPIR BREAST CYST,,19000,521,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,19001,"PUCT/ASPIR BREAST CYST,EACH ADDN",,19001,521,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,19020,EXPLO/DRAIN BREAST ABSCESS,,19020,521,"$1,910.00 ","$1,910.00 ",$534.80 ,"$1,747.65 ","$1,337.00 ","$1,598.67 ","$1,747.65 ","$1,747.65 ","$1,747.65 ",$703.84 ,"$1,146.00 ",$573.00 ,"$1,719.00 ","$1,432.50 ","$1,528.00 ","$1,585.30 "
Hoopeston Regional Hlth Center,19100,"BIOPSY OF BREAST, NEEDLE CORE",,19100,521,$850.00 ,$850.00 ,$238.00 ,$777.75 ,$595.00 ,$711.45 ,$777.75 ,$777.75 ,$777.75 ,$313.23 ,$510.00 ,$255.00 ,$765.00 ,$637.50 ,$680.00 ,$705.50
Hoopeston Regional Hlth Center,45330,SIGMOIDOSCOPY FLX DX W/COLLJ SPEC BR/WA IF PFRMD,,45330,521,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,11308,SHAV SKIN LES >2.1 CM REMAINDER BODY,,11308,521,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,45331,"SIGMOIDOSCOPY,BIOPSY",,45331,521,"$1,080.00 ","$1,080.00 ",$302.40 ,$988.20 ,$756.00 ,$903.96 ,$988.20 ,$988.20 ,$988.20 ,$397.98 ,$648.00 ,$324.00 ,$972.00 ,$810.00 ,$864.00 ,$896.40
Hoopeston Regional Hlth Center,45378,COLONOSCOPY FLX DX W/COLLJ SPEC WHEN PFRMD,,45378,521,"$2,470.00 ","$2,470.00 ",$691.60 ,"$2,260.05 ","$1,729.00 ","$2,067.39 ","$2,260.05 ","$2,260.05 ","$2,260.05 ",$910.20 ,"$1,482.00 ",$741.00 ,"$2,223.00 ","$1,852.50 ","$1,976.00 ","$2,050.10 "
Hoopeston Regional Hlth Center,45380,COLONOSCOPY W/BIOPSY SINGLE/MULTIPLE,,45380,521,"$2,950.00 ","$2,950.00 ",$826.00 ,"$2,699.25 ","$2,065.00 ","$2,469.15 ","$2,699.25 ","$2,699.25 ","$2,699.25 ","$1,087.08 ","$1,770.00 ",$885.00 ,"$2,655.00 ","$2,212.50 ","$2,360.00 ","$2,448.50 "
Hoopeston Regional Hlth Center,45385,COLSC FLX W/RMVL OF TUMOR POLYP LESION SNARE TQ,,45385,521,"$3,330.00 ","$3,330.00 ",$932.40 ,"$3,046.95 ","$2,331.00 ","$2,787.21 ","$3,046.95 ","$3,046.95 ","$3,046.95 ","$1,227.11 ","$1,998.00 ",$999.00 ,"$2,997.00 ","$2,497.50 ","$2,664.00 ","$2,763.90 "
Hoopeston Regional Hlth Center,46050,"I&D PERIANAL ABSCESS,SUPERFICIAL",,46050,521,$870.00 ,$870.00 ,$243.60 ,$796.05 ,$609.00 ,$728.19 ,$796.05 ,$796.05 ,$796.05 ,$320.60 ,$522.00 ,$261.00 ,$783.00 ,$652.50 ,$696.00 ,$722.10
Hoopeston Regional Hlth Center,46083,INCISE EXTERNAL HEMORRHOID,,46083,521,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,46600,ANOSCOPY DX W/COLLJ SPEC BR/WA SPX WHEN PRFRMD,,46600,521,$540.00 ,$540.00 ,$151.20 ,$494.10 ,$378.00 ,$451.98 ,$494.10 ,$494.10 ,$494.10 ,$198.99 ,$324.00 ,$162.00 ,$486.00 ,$405.00 ,$432.00 ,$448.20
Hoopeston Regional Hlth Center,11310,"SHAV SKIN LES <0.5 CM FACE,FACIAL",,11310,521,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,11311,"SHAV SKIN LES 0.6-1.0 CM FACE,FACIAL",,11311,521,$400.00 ,$400.00 ,$112.00 ,$366.00 ,$280.00 ,$334.80 ,$366.00 ,$366.00 ,$366.00 ,$147.40 ,$240.00 ,$120.00 ,$360.00 ,$300.00 ,$320.00 ,$332.00
Hoopeston Regional Hlth Center,10060,DRAIN SKIN ABSCESS SIMPLE,,10060,521,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,11312,"SHAV SKIN LES 1.1-2.0 CM FACE,FACIAL",,11312,521,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,51700,IRRIGATION OF BLADDER,,51700,521,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,51741,COMPLEX UROFLOWMETRY,,51741,521,$540.00 ,$540.00 ,$151.20 ,$494.10 ,$378.00 ,$451.98 ,$494.10 ,$494.10 ,$494.10 ,$198.99 ,$324.00 ,$162.00 ,$486.00 ,$405.00 ,$432.00 ,$448.20
Hoopeston Regional Hlth Center,52000,CYSTOURETHROSCOPY,,52000,521,"$1,050.00 ","$1,050.00 ",$294.00 ,$960.75 ,$735.00 ,$878.85 ,$960.75 ,$960.75 ,$960.75 ,$386.93 ,$630.00 ,$315.00 ,$945.00 ,$787.50 ,$840.00 ,$871.50
Hoopeston Regional Hlth Center,20520,REMOVAL OF FOREIGN BODY,,20520,521,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,54050,"DESTR PENIS LESN,SIMPL,CHEMICAL",,54050,521,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,54056,"DESTR PENIS LESN,SIMPL,CRYOSURG",,54056,521,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,20550,INJECT TENDON SHEATH/LIGAMENT,,20550,521,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,54150,"CIRCUMCISION,CLAMP,NEWBORN",,54150,521,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,54160,"CIRCUMCISION,OTHR,NEWBORN",,54160,521,"$1,110.00 ","$1,110.00 ",$310.80 ,"$1,015.65 ",$777.00 ,$929.07 ,"$1,015.65 ","$1,015.65 ","$1,015.65 ",$409.04 ,$666.00 ,$333.00 ,$999.00 ,$832.50 ,$888.00 ,$921.30
Hoopeston Regional Hlth Center,20600,ARTHROCENTESIS ASPIR&/INJ SMALL JT/BURSA W/O US,,20600,521,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,20605,ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/O US,,20605,521,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,11400,"EXC SKIN BENIG <0.5 CM TRUNK,ARM,LEG",,11400,521,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,20610,ARTHROCENTESIS ASPIR&/INJ MAJOR JT/BURSA W/O US,,20610,521,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,20650,INSERT AND REMOVE BONE PIN,,20650,521,$940.00 ,$940.00 ,$263.20 ,$860.10 ,$658.00 ,$786.78 ,$860.10 ,$860.10 ,$860.10 ,$346.39 ,$564.00 ,$282.00 ,$846.00 ,$705.00 ,$752.00 ,$780.20
Hoopeston Regional Hlth Center,55250,REMOVAL OF SPERM DUCT(S),,55250,521,"$1,640.00 ","$1,640.00 ",$459.20 ,"$1,500.60 ","$1,148.00 ","$1,372.68 ","$1,500.60 ","$1,500.60 ","$1,500.60 ",$604.34 ,$984.00 ,$492.00 ,"$1,476.00 ","$1,230.00 ","$1,312.00 ","$1,361.20 "
Hoopeston Regional Hlth Center,56405,I&D OF VULVA/PERINEUM ABSCESS,,56405,521,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,56420,I&D BARTHOLIN GLAND ABSCESS,,56420,521,$840.00 ,$840.00 ,$235.20 ,$768.60 ,$588.00 ,$703.08 ,$768.60 ,$768.60 ,$768.60 ,$309.54 ,$504.00 ,$252.00 ,$756.00 ,$630.00 ,$672.00 ,$697.20
Hoopeston Regional Hlth Center,56441,LYSIS OF LABIAL LESION(S),,56441,521,$960.00 ,$960.00 ,$268.80 ,$878.40 ,$672.00 ,$803.52 ,$878.40 ,$878.40 ,$878.40 ,$353.76 ,$576.00 ,$288.00 ,$864.00 ,$720.00 ,$768.00 ,$796.80
Hoopeston Regional Hlth Center,56501,"DESTRUCTION,LESION(S),VULVA,SIMPLE",,56501,521,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,56515,"DESTRUCTION,LESION(S),VULVA;EXTENSIVE",,56515,521,"$1,730.00 ","$1,730.00 ",$484.40 ,"$1,582.95 ","$1,211.00 ","$1,448.01 ","$1,582.95 ","$1,582.95 ","$1,582.95 ",$637.51 ,"$1,038.00 ",$519.00 ,"$1,557.00 ","$1,297.50 ","$1,384.00 ","$1,435.90 "
Hoopeston Regional Hlth Center,56605,"BIOPSY VULVA/PERINEUM,ONE LESN",,56605,521,$620.00 ,$620.00 ,$173.60 ,$567.30 ,$434.00 ,$518.94 ,$567.30 ,$567.30 ,$567.30 ,$228.47 ,$372.00 ,$186.00 ,$558.00 ,$465.00 ,$496.00 ,$514.60
Hoopeston Regional Hlth Center,56606,"BX,VULVA/PERINEUM,ADDL LESION",,56606,521,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,11401,"EXC SKIN BENIG 0.6-1 CM TRUNK,ARM,LEG",,11401,521,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,57061,"DESTRUCT,VAGINAL LESION(S),SIMPLE",,57061,521,"$1,280.00 ","$1,280.00 ",$358.40 ,"$1,171.20 ",$896.00 ,"$1,071.36 ","$1,171.20 ","$1,171.20 ","$1,171.20 ",$471.68 ,$768.00 ,$384.00 ,"$1,152.00 ",$960.00 ,"$1,024.00 ","$1,062.40 "
Hoopeston Regional Hlth Center,57100,"BIOPSY OF VAGINA,SIMPLE",,57100,521,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,57160,FIT/INSERT INTRAVAG SUPPORT DEVICE,,57160,521,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,57170,FITTING OF DIAPHRAGM/CAP,,57170,521,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,57452,"COLPOSCOPY,CERVIX W/ADJ VAGINA",,57452,521,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,57454,"COLPOSC,CERVIX W/ADJ VAG,W/BX & CURRETAG",,57454,521,$970.00 ,$970.00 ,$271.60 ,$887.55 ,$679.00 ,$811.89 ,$887.55 ,$887.55 ,$887.55 ,$357.45 ,$582.00 ,$291.00 ,$873.00 ,$727.50 ,$776.00 ,$805.10
Hoopeston Regional Hlth Center,57500,"BIOPSY CERVIX, 1 OR MORE, OR EXCISION OF LESION",,57500,521,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,57505,ENDOCERVICAL CURETTAGE,,57505,521,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,57511,CRYOCAUTERY OF CERVIX,,57511,521,$830.00 ,$830.00 ,$232.40 ,$759.45 ,$581.00 ,$694.71 ,$759.45 ,$759.45 ,$759.45 ,$305.86 ,$498.00 ,$249.00 ,$747.00 ,$622.50 ,$664.00 ,$688.90
Hoopeston Regional Hlth Center,57522,"CONIZATION CERVIX,LOOP ELECTRD",,57522,521,"$2,110.00 ","$2,110.00 ",$590.80 ,"$1,930.65 ","$1,477.00 ","$1,766.07 ","$1,930.65 ","$1,930.65 ","$1,930.65 ",$777.54 ,"$1,266.00 ",$633.00 ,"$1,899.00 ","$1,582.50 ","$1,688.00 ","$1,751.30 "
Hoopeston Regional Hlth Center,57800,DILATION OF CERVICAL CANAL,,57800,521,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,58100,BIOPSY OF UTERUS LINING,,58100,521,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,58300,INSERT INTRAUTERINE DEVICE,,58300,521,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,58301,REMOVE INTRAUTERINE DEVICE,,58301,521,$485.00 ,$485.00 ,$135.80 ,$443.78 ,$339.50 ,$405.95 ,$443.78 ,$443.78 ,$443.78 ,$178.72 ,$291.00 ,$145.50 ,$436.50 ,$363.75 ,$388.00 ,$402.55
Hoopeston Regional Hlth Center,58321,"ARTIF INSEMINATION,INTRA-CERVICAL",,58321,521,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,58322,"ARTIF INSEMINATION,INTRA-UTERINE",,58322,521,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,58323,SPERM WASHING FOR ARTIF INSEM,,58323,521,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,58340,CATH/INJECT HYSTEROSALPINGOGRAM,,58340,521,$920.00 ,$920.00 ,$257.60 ,$841.80 ,$644.00 ,$770.04 ,$841.80 ,$841.80 ,$841.80 ,$339.02 ,$552.00 ,$276.00 ,$828.00 ,$690.00 ,$736.00 ,$763.60
Hoopeston Regional Hlth Center,58605,"LIGATE FALLOPIAN TUBE,POSTPARTUM",,58605,521,"$3,320.00 ","$3,320.00 ",$929.60 ,"$3,037.80 ","$2,324.00 ","$2,778.84 ","$3,037.80 ","$3,037.80 ","$3,037.80 ","$1,223.42 ","$1,992.00 ",$996.00 ,"$2,988.00 ","$2,490.00 ","$2,656.00 ","$2,755.60 "
Hoopeston Regional Hlth Center,58611,"LIGATION,FALLOPIAN TUBE W/C-SECTION",,58611,521,"$1,520.00 ","$1,520.00 ",$425.60 ,"$1,390.80 ","$1,064.00 ","$1,272.24 ","$1,390.80 ","$1,390.80 ","$1,390.80 ",$560.12 ,$912.00 ,$456.00 ,"$1,368.00 ","$1,140.00 ","$1,216.00 ","$1,261.60 "
Hoopeston Regional Hlth Center,11402,"EXC SKIN BENIG 1.1-2 CM TRUNK,ARM,LEG",,11402,521,$720.00 ,$720.00 ,$201.60 ,$658.80 ,$504.00 ,$602.64 ,$658.80 ,$658.80 ,$658.80 ,$265.32 ,$432.00 ,$216.00 ,$648.00 ,$540.00 ,$576.00 ,$597.60
Hoopeston Regional Hlth Center,59000,"AMNIOCENTESIS,DIAGNOSTIC",,59000,521,$960.00 ,$960.00 ,$268.80 ,$878.40 ,$672.00 ,$803.52 ,$878.40 ,$878.40 ,$878.40 ,$353.76 ,$576.00 ,$288.00 ,$864.00 ,$720.00 ,$768.00 ,$796.80
Hoopeston Regional Hlth Center,59020,FETAL CONTRACTN STRESS TEST,,59020,521,$490.00 ,$490.00 ,$137.20 ,$448.35 ,$343.00 ,$410.13 ,$448.35 ,$448.35 ,$448.35 ,$180.57 ,$294.00 ,$147.00 ,$441.00 ,$367.50 ,$392.00 ,$406.70
Hoopeston Regional Hlth Center,59025,FETAL NON-STRESS TEST,,59025,521,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,59160,D&C AFTER DELIVERY,,59160,521,"$1,710.00 ","$1,710.00 ",$478.80 ,"$1,564.65 ","$1,197.00 ","$1,431.27 ","$1,564.65 ","$1,564.65 ","$1,564.65 ",$630.14 ,"$1,026.00 ",$513.00 ,"$1,539.00 ","$1,282.50 ","$1,368.00 ","$1,419.30 "
Hoopeston Regional Hlth Center,59200,INSERT CERVICAL DILATOR,,59200,521,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,59320,"REVISION CERVIX W PREG,VAG APPRCH",,59320,521,"$1,890.00 ","$1,890.00 ",$529.20 ,"$1,729.35 ","$1,323.00 ","$1,581.93 ","$1,729.35 ","$1,729.35 ","$1,729.35 ",$696.47 ,"$1,134.00 ",$567.00 ,"$1,701.00 ","$1,417.50 ","$1,512.00 ","$1,568.70 "
Hoopeston Regional Hlth Center,59400,"FULL ROUT OBSTE CARE,VAGINAL DELIV",,59400,521,"$7,400.00 ","$7,400.00 ","$2,072.00 ","$6,771.00 ","$5,180.00 ","$6,193.80 ","$6,771.00 ","$6,771.00 ","$6,771.00 ","$2,726.90 ","$4,440.00 ","$2,220.00 ","$6,660.00 ","$5,550.00 ","$5,920.00 ","$6,142.00 "
Hoopeston Regional Hlth Center,59409,"OBSTETRICAL CARE,VAG DELIV ONLY",,59409,521,"$3,880.00 ","$3,880.00 ","$1,086.40 ","$3,550.20 ","$2,716.00 ","$3,247.56 ","$3,550.20 ","$3,550.20 ","$3,550.20 ","$1,429.78 ","$2,328.00 ","$1,164.00 ","$3,492.00 ","$2,910.00 ","$3,104.00 ","$3,220.40 "
Hoopeston Regional Hlth Center,59410,"OBSTE CARE,VAG DELIV+POSTPARTUM",,59410,521,"$4,750.00 ","$4,750.00 ","$1,330.00 ","$4,346.25 ","$3,325.00 ","$3,975.75 ","$4,346.25 ","$4,346.25 ","$4,346.25 ","$1,750.38 ","$2,850.00 ","$1,425.00 ","$4,275.00 ","$3,562.50 ","$3,800.00 ","$3,942.50 "
Hoopeston Regional Hlth Center,59412,ANTEPARTUM HEAD MANIPULATION,,59412,521,"$1,130.00 ","$1,130.00 ",$316.40 ,"$1,033.95 ",$791.00 ,$945.81 ,"$1,033.95 ","$1,033.95 ","$1,033.95 ",$416.41 ,$678.00 ,$339.00 ,"$1,017.00 ",$847.50 ,$904.00 ,$937.90
Hoopeston Regional Hlth Center,59414,DELIVER PLACENTA,,59414,521,$990.00 ,$990.00 ,$277.20 ,$905.85 ,$693.00 ,$828.63 ,$905.85 ,$905.85 ,$905.85 ,$364.82 ,$594.00 ,$297.00 ,$891.00 ,$742.50 ,$792.00 ,$821.70
Hoopeston Regional Hlth Center,59425,"ANTEPARTUM CARE ONLY, 4-6 VISITS",,59425,521,"$1,290.00 ","$1,290.00 ",$361.20 ,"$1,180.35 ",$903.00 ,"$1,079.73 ","$1,180.35 ","$1,180.35 ","$1,180.35 ",$475.37 ,$774.00 ,$387.00 ,"$1,161.00 ",$967.50 ,"$1,032.00 ","$1,070.70 "
Hoopeston Regional Hlth Center,59426,"ANTEPARTUM CARE ONLY, >7 VISITS",,59426,521,"$3,140.00 ","$3,140.00 ",$879.20 ,"$2,873.10 ","$2,198.00 ","$2,628.18 ","$2,873.10 ","$2,873.10 ","$2,873.10 ","$1,157.09 ","$1,884.00 ",$942.00 ,"$2,826.00 ","$2,355.00 ","$2,512.00 ","$2,606.20 "
Hoopeston Regional Hlth Center,59430,CARE AFTER DELIVERY ONLY,,59430,521,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,59510,"FULL ROUT OBSTE CARE,CESAREAN DELIV",,59510,521,"$8,630.00 ","$8,630.00 ","$2,416.40 ","$7,896.45 ","$6,041.00 ","$7,223.31 ","$7,896.45 ","$7,896.45 ","$7,896.45 ","$3,180.16 ","$5,178.00 ","$2,589.00 ","$7,767.00 ","$6,472.50 ","$6,904.00 ","$7,162.90 "
Hoopeston Regional Hlth Center,59514,CESAREAN DELIVERY ONLY,,59514,521,"$4,700.00 ","$4,700.00 ","$1,316.00 ","$4,300.50 ","$3,290.00 ","$3,933.90 ","$4,300.50 ","$4,300.50 ","$4,300.50 ","$1,731.95 ","$2,820.00 ","$1,410.00 ","$4,230.00 ","$3,525.00 ","$3,760.00 ","$3,901.00 "
Hoopeston Regional Hlth Center,59515,CESAREAN DELIVERY+POSTPARTUM CARE,,59515,521,"$5,610.00 ","$5,610.00 ","$1,570.80 ","$5,133.15 ","$3,927.00 ","$4,695.57 ","$5,133.15 ","$5,133.15 ","$5,133.15 ","$2,067.29 ","$3,366.00 ","$1,683.00 ","$5,049.00 ","$4,207.50 ","$4,488.00 ","$4,656.30 "
Hoopeston Regional Hlth Center,59525,REMOVE UTERUS AFTER CESAREAN,,59525,521,"$3,360.00 ","$3,360.00 ",$940.80 ,"$3,074.40 ","$2,352.00 ","$2,812.32 ","$3,074.40 ","$3,074.40 ","$3,074.40 ","$1,238.16 ","$2,016.00 ","$1,008.00 ","$3,024.00 ","$2,520.00 ","$2,688.00 ","$2,788.80 "
Hoopeston Regional Hlth Center,59610,"ROUT OB CARE,VAG DELIV,PREV C-SEC",,59610,521,"$8,260.00 ","$8,260.00 ","$2,312.80 ","$7,557.90 ","$5,782.00 ","$6,913.62 ","$7,557.90 ","$7,557.90 ","$7,557.90 ","$3,043.81 ","$4,956.00 ","$2,478.00 ","$7,434.00 ","$6,195.00 ","$6,608.00 ","$6,855.80 "
Hoopeston Regional Hlth Center,59614,"VAG DELIV+POSTPARTUM CARE,PREV C-SEC",,59614,521,"$5,330.00 ","$5,330.00 ","$1,492.40 ","$4,876.95 ","$3,731.00 ","$4,461.21 ","$4,876.95 ","$4,876.95 ","$4,876.95 ","$1,964.11 ","$3,198.00 ","$1,599.00 ","$4,797.00 ","$3,997.50 ","$4,264.00 ","$4,423.90 "
Hoopeston Regional Hlth Center,59618,"ROUT OB CARE,C-SEC,PREV C-SEC",,59618,521,"$9,520.00 ","$9,520.00 ","$2,665.60 ","$8,710.80 ","$6,664.00 ","$7,968.24 ","$8,710.80 ","$8,710.80 ","$8,710.80 ","$3,508.12 ","$5,712.00 ","$2,856.00 ","$8,568.00 ","$7,140.00 ","$7,616.00 ","$7,901.60 "
Hoopeston Regional Hlth Center,59622,"C-SEC+POSTPARTUM CARE,PREV C-SEC",,59622,521,"$6,480.00 ","$6,480.00 ","$1,814.40 ","$5,929.20 ","$4,536.00 ","$5,423.76 ","$5,929.20 ","$5,929.20 ","$5,929.20 ","$2,387.88 ","$3,888.00 ","$1,944.00 ","$5,832.00 ","$4,860.00 ","$5,184.00 ","$5,378.40 "
Hoopeston Regional Hlth Center,59812,SURG RX INCOMPLETE ABORTN,,59812,521,"$2,030.00 ","$2,030.00 ",$568.40 ,"$1,857.45 ","$1,421.00 ","$1,699.11 ","$1,857.45 ","$1,857.45 ","$1,857.45 ",$748.06 ,"$1,218.00 ",$609.00 ,"$1,827.00 ","$1,522.50 ","$1,624.00 ","$1,684.90 "
Hoopeston Regional Hlth Center,59820,"SURG RX MISSED ABORTN,1ST TRI",,59820,521,"$2,010.00 ","$2,010.00 ",$562.80 ,"$1,839.15 ","$1,407.00 ","$1,682.37 ","$1,839.15 ","$1,839.15 ","$1,839.15 ",$740.69 ,"$1,206.00 ",$603.00 ,"$1,809.00 ","$1,507.50 ","$1,608.00 ","$1,668.30 "
Hoopeston Regional Hlth Center,59821,"SURG RX MISSED ABORTN,2ND TRI",,59821,521,"$2,640.00 ","$2,640.00 ",$739.20 ,"$2,415.60 ","$1,848.00 ","$2,209.68 ","$2,415.60 ","$2,415.60 ","$2,415.60 ",$972.84 ,"$1,584.00 ",$792.00 ,"$2,376.00 ","$1,980.00 ","$2,112.00 ","$2,191.20 "
Hoopeston Regional Hlth Center,11403,"EXC SKIN BENIG 2.1-3 CM TRUNK,ARM,LEG",,11403,521,$960.00 ,$960.00 ,$268.80 ,$878.40 ,$672.00 ,$803.52 ,$878.40 ,$878.40 ,$878.40 ,$353.76 ,$576.00 ,$288.00 ,$864.00 ,$720.00 ,$768.00 ,$796.80
Hoopeston Regional Hlth Center,61070,BRAIN SHUNT TUBE/RESERV INJECTN,,61070,521,"$1,170.00 ","$1,170.00 ",$327.60 ,"$1,070.55 ",$819.00 ,$979.29 ,"$1,070.55 ","$1,070.55 ","$1,070.55 ",$431.15 ,$702.00 ,$351.00 ,"$1,053.00 ",$877.50 ,$936.00 ,$971.10
Hoopeston Regional Hlth Center,61210,BURR HOLE IMPLANT CATH/DEVICE,,61210,521,"$4,960.00 ","$4,960.00 ","$1,388.80 ","$4,538.40 ","$3,472.00 ","$4,151.52 ","$4,538.40 ","$4,538.40 ","$4,538.40 ","$1,827.76 ","$2,976.00 ","$1,488.00 ","$4,464.00 ","$3,720.00 ","$3,968.00 ","$4,116.80 "
Hoopeston Regional Hlth Center,11404,"EXC SKIN BENIG 3.1-4 CM TRUNK,ARM,LEG",,11404,521,"$1,060.00 ","$1,060.00 ",$296.80 ,$969.90 ,$742.00 ,$887.22 ,$969.90 ,$969.90 ,$969.90 ,$390.61 ,$636.00 ,$318.00 ,$954.00 ,$795.00 ,$848.00 ,$879.80
Hoopeston Regional Hlth Center,21015,RAD RESECTION TUMOR SOFT TISS FACE/SCALP < 2CM,,21015,521,"$4,040.00 ","$4,040.00 ","$1,131.20 ","$3,696.60 ","$2,828.00 ","$3,381.48 ","$3,696.60 ","$3,696.60 ","$3,696.60 ","$1,488.74 ","$2,424.00 ","$1,212.00 ","$3,636.00 ","$3,030.00 ","$3,232.00 ","$3,353.20 "
Hoopeston Regional Hlth Center,62270,"SPINAL PUNCTURE,LUMBAR,DIAGNOSTIC",,62270,521,$830.00 ,$830.00 ,$232.40 ,$759.45 ,$581.00 ,$694.71 ,$759.45 ,$759.45 ,$759.45 ,$305.86 ,$498.00 ,$249.00 ,$747.00 ,$622.50 ,$664.00 ,$688.90
Hoopeston Regional Hlth Center,11406,"EXC SKIN BENIG >4 CM TRUNK,ARM,LEG",,11406,521,"$1,520.00 ","$1,520.00 ",$425.60 ,"$1,390.80 ","$1,064.00 ","$1,272.24 ","$1,390.80 ","$1,390.80 ","$1,390.80 ",$560.12 ,$912.00 ,$456.00 ,"$1,368.00 ","$1,140.00 ","$1,216.00 ","$1,261.60 "
Hoopeston Regional Hlth Center,64405,"INJECT NERV BLCK,GREAT OCCIPTL",,64405,521,$970.00 ,$970.00 ,$271.60 ,$887.55 ,$679.00 ,$811.89 ,$887.55 ,$887.55 ,$887.55 ,$357.45 ,$582.00 ,$291.00 ,$873.00 ,$727.50 ,$776.00 ,$805.10
Hoopeston Regional Hlth Center,11420,EXC SKIN BENIG <0.5 CM REMAINDER BODY,,11420,521,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,64450,"INJECT NERV BLCK,OTHR PERIPH NERV",,64450,521,$760.00 ,$760.00 ,$212.80 ,$695.40 ,$532.00 ,$636.12 ,$695.40 ,$695.40 ,$695.40 ,$280.06 ,$456.00 ,$228.00 ,$684.00 ,$570.00 ,$608.00 ,$630.80
Hoopeston Regional Hlth Center,64612,CHEMODNRVTJ MUSC MUSC INNERVATED FACIAL NRV UNIL,,64612,521,"$1,200.00 ","$1,200.00 ",$336.00 ,"$1,098.00 ",$840.00 ,"$1,004.40 ","$1,098.00 ","$1,098.00 ","$1,098.00 ",$442.20 ,$720.00 ,$360.00 ,"$1,080.00 ",$900.00 ,$960.00 ,$996.00
Hoopeston Regional Hlth Center,64721,REVISE MEDIAN N/CARPAL TUNNEL SURG,,64721,521,"$4,620.00 ","$4,620.00 ","$1,293.60 ","$4,227.30 ","$3,234.00 ","$3,866.94 ","$4,227.30 ","$4,227.30 ","$4,227.30 ","$1,702.47 ","$2,772.00 ","$1,386.00 ","$4,158.00 ","$3,465.00 ","$3,696.00 ","$3,834.60 "
Hoopeston Regional Hlth Center,11421,EXC SKIN BENIG 0.6-1 CM REMAINDR BODY,,11421,521,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,10061,DRAIN SKIN ABSCESS COMPLIC,,10061,521,$970.00 ,$970.00 ,$271.60 ,$887.55 ,$679.00 ,$811.89 ,$887.55 ,$887.55 ,$887.55 ,$357.45 ,$582.00 ,$291.00 ,$873.00 ,$727.50 ,$776.00 ,$805.10
Hoopeston Regional Hlth Center,65205,"REMV F.B.,EYE,SUPERF CONJUNC",,65205,521,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,65220,"REMV F.B.,EYE,CORNEA,NO SLIT",,65220,521,$410.00 ,$410.00 ,$114.80 ,$375.15 ,$287.00 ,$343.17 ,$375.15 ,$375.15 ,$375.15 ,$151.09 ,$246.00 ,$123.00 ,$369.00 ,$307.50 ,$328.00 ,$340.30
Hoopeston Regional Hlth Center,11422,EXC SKIN BENIG 1.1-2 CM REMAINDR BODY,,11422,521,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,11423,EXC SKIN BENIG 2.1-3 CM REMAINDR BODY,,11423,521,$980.00 ,$980.00 ,$274.40 ,$896.70 ,$686.00 ,$820.26 ,$896.70 ,$896.70 ,$896.70 ,$361.13 ,$588.00 ,$294.00 ,$882.00 ,$735.00 ,$784.00 ,$813.40
Hoopeston Regional Hlth Center,69200,REMV EXT CANAL FOREIGN BODY,,69200,521,$475.00 ,$475.00 ,$133.00 ,$434.63 ,$332.50 ,$397.58 ,$434.63 ,$434.63 ,$434.63 ,$175.04 ,$285.00 ,$142.50 ,$427.50 ,$356.25 ,$380.00 ,$394.25
Hoopeston Regional Hlth Center,69210,REMOVAL IMPACTED CERUMEN INSTRUMENTATION UNILAT,,69210,521,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,69610,REPAIR TYMPANIC MEMBRANE,,69610,521,"$1,510.00 ","$1,510.00 ",$422.80 ,"$1,381.65 ","$1,057.00 ","$1,263.87 ","$1,381.65 ","$1,381.65 ","$1,381.65 ",$556.44 ,$906.00 ,$453.00 ,"$1,359.00 ","$1,132.50 ","$1,208.00 ","$1,253.30 "
Hoopeston Regional Hlth Center,11424,EXC SKIN BENIG 3.1-4 CM REMAINDR BODY,,11424,521,"$1,190.00 ","$1,190.00 ",$333.20 ,"$1,088.85 ",$833.00 ,$996.03 ,"$1,088.85 ","$1,088.85 ","$1,088.85 ",$438.52 ,$714.00 ,$357.00 ,"$1,071.00 ",$892.50 ,$952.00 ,$987.70
Hoopeston Regional Hlth Center,11426,EXC SKIN BENIG >4 CM REMAINDR BODY,,11426,521,"$1,680.00 ","$1,680.00 ",$470.40 ,"$1,537.20 ","$1,176.00 ","$1,406.16 ","$1,537.20 ","$1,537.20 ","$1,537.20 ",$619.08 ,"$1,008.00 ",$504.00 ,"$1,512.00 ","$1,260.00 ","$1,344.00 ","$1,394.40 "
Hoopeston Regional Hlth Center,11440,"EXC SKIN BENIG <0.5 CM FACE,FACIAL",,11440,521,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,11441,"EXC SKIN BENIG 0.6-1 CM FACE,FACIAL",,11441,521,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,11442,"EXC SKIN BENIG 1.1-2 CM FACE,FACIAL",,11442,521,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,11443,"EXC SKIN BENIG 2.1-3 CM FACE,FACIAL",,11443,521,"$1,110.00 ","$1,110.00 ",$310.80 ,"$1,015.65 ",$777.00 ,$929.07 ,"$1,015.65 ","$1,015.65 ","$1,015.65 ",$409.04 ,$666.00 ,$333.00 ,$999.00 ,$832.50 ,$888.00 ,$921.30
Hoopeston Regional Hlth Center,11444,"EXC SKIN BENIG 3.1- 4 CM FACE,FACIAL",,11444,521,"$1,340.00 ","$1,340.00 ",$375.20 ,"$1,226.10 ",$938.00 ,"$1,121.58 ","$1,226.10 ","$1,226.10 ","$1,226.10 ",$493.79 ,$804.00 ,$402.00 ,"$1,206.00 ","$1,005.00 ","$1,072.00 ","$1,112.20 "
Hoopeston Regional Hlth Center,11446,"EXC SKIN BENIG >4 CM FACE,FACIAL",,11446,521,"$2,240.00 ","$2,240.00 ",$627.20 ,"$2,049.60 ","$1,568.00 ","$1,874.88 ","$2,049.60 ","$2,049.60 ","$2,049.60 ",$825.44 ,"$1,344.00 ",$672.00 ,"$2,016.00 ","$1,680.00 ","$1,792.00 ","$1,859.20 "
Hoopeston Regional Hlth Center,10080,DRAIN PILONIDAL CYST SIMPL,,10080,521,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,92012,"EYE EXAM, EST PATIENT,INTERMED",,92012,521,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,92014,"EYE EXAM, EST PATIENT,COMPREHESV",,92014,521,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,92551,"PURE TONE HEARING TEST, AIR",,92551,521,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,92552,"PURE TONE AUDIOMETRY, AIR",,92552,521,$95.00 ,$95.00 ,$26.60 ,$86.93 ,$66.50 ,$79.52 ,$86.93 ,$86.93 ,$86.93 ,$35.01 ,$57.00 ,$28.50 ,$85.50 ,$71.25 ,$76.00 ,$78.85
Hoopeston Regional Hlth Center,92950,HEART/LUNG RESUSCITATION (CPR),,92950,521,"$1,360.00 ","$1,360.00 ",$380.80 ,"$1,244.40 ",$952.00 ,"$1,138.32 ","$1,244.40 ","$1,244.40 ","$1,244.40 ",$501.16 ,$816.00 ,$408.00 ,"$1,224.00 ","$1,020.00 ","$1,088.00 ","$1,128.80 "
Hoopeston Regional Hlth Center,95115,"IMMUNOTHERAPY, ONE INJECTION",,95115,521,$50.00 ,$50.00 ,$14.00 ,$45.75 ,$35.00 ,$41.85 ,$45.75 ,$45.75 ,$45.75 ,$18.43 ,$30.00 ,$15.00 ,$45.00 ,$37.50 ,$40.00 ,$41.50
Hoopeston Regional Hlth Center,95117,"IMMUNOTHERAPY, 2+ INJECTIONS",,95117,521,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,21555,EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBQ <3CM,,21555,521,"$2,290.00 ","$2,290.00 ",$641.20 ,"$2,095.35 ","$1,603.00 ","$1,916.73 ","$2,095.35 ","$2,095.35 ","$2,095.35 ",$843.87 ,"$1,374.00 ",$687.00 ,"$2,061.00 ","$1,717.50 ","$1,832.00 ","$1,900.70 "
Hoopeston Regional Hlth Center,21556,EXC TUMOR SOFT TISSUE NECK/ANT THORAX SUBFASCIAL <5CM,,21556,521,"$2,960.00 ","$2,960.00 ",$828.80 ,"$2,708.40 ","$2,072.00 ","$2,477.52 ","$2,708.40 ","$2,708.40 ","$2,708.40 ","$1,090.76 ","$1,776.00 ",$888.00 ,"$2,664.00 ","$2,220.00 ","$2,368.00 ","$2,456.80 "
Hoopeston Regional Hlth Center,21557,RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX <5CM,,21557,521,"$6,030.00 ","$6,030.00 ","$1,688.40 ","$5,517.45 ","$4,221.00 ","$5,047.11 ","$5,517.45 ","$5,517.45 ","$5,517.45 ","$2,222.06 ","$3,618.00 ","$1,809.00 ","$5,427.00 ","$4,522.50 ","$4,824.00 ","$5,004.90 "
Hoopeston Regional Hlth Center,99201,OFFICE OUTPATIENT NEW LEVEL 1,,99201,521,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,99202,OFFICE/OUTPATIENT NEW SF MDM,,99202,521,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,99203,OFFICE/OUTPATIENT NEW LOW MDM,,99203,521,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,99204,OFFICE/OUTPATIENT NEW MODERATE MDM,,99204,521,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,99205,OFFICE/OUTPATIENT NEW HIGH MDM,,99205,521,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,99211,OFFICE/OUTPATIENT ESTABLISHED MINIMAL PROBLEM(S),,99211,521,$84.00 ,$84.00 ,$23.52 ,$76.86 ,$58.80 ,$70.31 ,$76.86 ,$76.86 ,$76.86 ,$30.95 ,$50.40 ,$25.20 ,$75.60 ,$63.00 ,$67.20 ,$69.72
Hoopeston Regional Hlth Center,99212,OFFICE/OUTPATIENT ESTABLISHED SF MDM,,99212,521,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,99213,OFFICE/OUTPATIENT ESTABLISHED LOW MDM,,99213,521,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,99214,OFFICE/OUTPATIENT ESTABLISHED MOD MDM,,99214,521,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,99215,OFFICE/OUTPATIENT ESTABLISHED HIGH MDM,,99215,521,$410.00 ,$410.00 ,$114.80 ,$375.15 ,$287.00 ,$343.17 ,$375.15 ,$375.15 ,$375.15 ,$151.09 ,$246.00 ,$123.00 ,$369.00 ,$307.50 ,$328.00 ,$340.30
Hoopeston Regional Hlth Center,99241,OFFICE CONSULTATION NEW/ESTAB PATIENT LEVEL 1,,99241,521,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,99242,OFFICE CONSULTATION NEW/ESTAB PATIENT LEVEL 2,,99242,521,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,99243,OFFICE CONSULTATION NEW/ESTAB PATIENT LEVEL 3,,99243,521,$435.00 ,$435.00 ,$121.80 ,$398.03 ,$304.50 ,$364.10 ,$398.03 ,$398.03 ,$398.03 ,$160.30 ,$261.00 ,$130.50 ,$391.50 ,$326.25 ,$348.00 ,$361.05
Hoopeston Regional Hlth Center,99244,OFFICE CONSULTATION NEW/ESTAB PATIENT LEVEL 4,,99244,521,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,99245,OFFICE CONSULTATION NEW/ESTAB PATIENT LEVEL 5,,99245,521,$780.00 ,$780.00 ,$218.40 ,$713.70 ,$546.00 ,$652.86 ,$713.70 ,$713.70 ,$713.70 ,$287.43 ,$468.00 ,$234.00 ,$702.00 ,$585.00 ,$624.00 ,$647.40
Hoopeston Regional Hlth Center,99291,"CRITICAL CARE, E/M 30-74 MINUTES",,99291,521,"$1,280.00 ","$1,280.00 ",$358.40 ,"$1,171.20 ",$896.00 ,"$1,071.36 ","$1,171.20 ","$1,171.20 ","$1,171.20 ",$471.68 ,$768.00 ,$384.00 ,"$1,152.00 ",$960.00 ,"$1,024.00 ","$1,062.40 "
Hoopeston Regional Hlth Center,99292,"CRITICAL CARE, ADDL 30 MIN",,99292,521,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,99354,PROLONGED SVC OUTPATIENT SETTING 1ST HOUR,,99354,521,$485.00 ,$485.00 ,$135.80 ,$443.78 ,$339.50 ,$405.95 ,$443.78 ,$443.78 ,$443.78 ,$178.72 ,$291.00 ,$145.50 ,$436.50 ,$363.75 ,$388.00 ,$402.55
Hoopeston Regional Hlth Center,99355,PROLONGED SVC OUTPATIENT SETTING EA ADDL 30 MIN,,99355,521,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,99358,PROLNG E/M SVC BEFORE&/AFTER DIR PT CARE 1ST HR,,99358,521,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,99359,PROLNG E/M BEFORE&/AFTER DIR CARE EA 30 MIN,,99359,521,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,99375,SUPERVISION PT HOME HEALTH AGENCY MONTH 30 MIN/>,,99375,521,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,99381,"PREVENTIVE VISIT,NEW,INFANT < 1 YR",,99381,521,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,99382,"PREVENTIVE VISIT,NEW,AGE 1-4",,99382,521,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,99383,"PREVENTIVE VISIT,NEW,AGE5-11",,99383,521,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,99384,"PREVENTIVE VISIT,NEW,12-17",,99384,521,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,99385,"PREVENTIVE VISIT,NEW,18-39",,99385,521,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,99386,"PREVENTIVE VISIT,NEW,40-64",,99386,521,$425.00 ,$425.00 ,$119.00 ,$388.88 ,$297.50 ,$355.73 ,$388.88 ,$388.88 ,$388.88 ,$156.61 ,$255.00 ,$127.50 ,$382.50 ,$318.75 ,$340.00 ,$352.75
Hoopeston Regional Hlth Center,99387,"PREVENTIVE VISIT,NEW,65 & OVER",,99387,521,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,99391,"PREVENTIVE VISIT,EST, INFANT < 1 YR",,99391,521,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,99392,"PREVENTIVE VISIT,EST,AGE 1-4",,99392,521,$220.00 ,$220.00 ,$61.60 ,$201.30 ,$154.00 ,$184.14 ,$201.30 ,$201.30 ,$201.30 ,$81.07 ,$132.00 ,$66.00 ,$198.00 ,$165.00 ,$176.00 ,$182.60
Hoopeston Regional Hlth Center,99393,"PREVENTIVE VISIT,EST,AGE5-11",,99393,521,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,99394,"PREVENTIVE VISIT,EST,12-17",,99394,521,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,99395,"PREVENTIVE VISIT,EST,18-39",,99395,521,$290.00 ,$290.00 ,$81.20 ,$265.35 ,$203.00 ,$242.73 ,$265.35 ,$265.35 ,$265.35 ,$106.87 ,$174.00 ,$87.00 ,$261.00 ,$217.50 ,$232.00 ,$240.70
Hoopeston Regional Hlth Center,99396,"PREVENTIVE VISIT,EST,40-64",,99396,521,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,99397,"PREVENTIVE VISIT,EST,65 & OVER",,99397,521,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,99402,"PREVENT COUNSEL,INDIV,30 MIN",,99402,521,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,99403,"PREVENT COUNSEL,INDIV,45 MIN",,99403,521,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,99450,LIFE/DISABILITY EVALUATION,,99450,521,$220.00 ,$220.00 ,$61.60 ,$201.30 ,$154.00 ,$184.14 ,$201.30 ,$201.30 ,$201.30 ,$81.07 ,$132.00 ,$66.00 ,$198.00 ,$165.00 ,$176.00 ,$182.60
Hoopeston Regional Hlth Center,99455,DISABILITY EXAM/TREATING DR,,99455,521,$325.00 ,$325.00 ,$91.00 ,$297.38 ,$227.50 ,$272.03 ,$297.38 ,$297.38 ,$297.38 ,$119.76 ,$195.00 ,$97.50 ,$292.50 ,$243.75 ,$260.00 ,$269.75
Hoopeston Regional Hlth Center,Q0091,Obtaining screen pap smear,,Q0091,521,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,11720,"DEBRIDEMENT OF NAIL(S), 1-5",,11720,521,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,11721,"DEBRIDEMENT OF NAILS, 6 OR MORE",,11721,521,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,11055,"TRIM HYPERKERATOTIC SKIN LESION, ONE",,11055,521,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,11056,"TRIM BENIGN HYPERKERATOTIC SKIN LESION,2-4",,11056,521,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,11057,"TRIM BENIGN HYPERKERATOTIC SKIN LESION,>4",,11057,521,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,11719,TRIM NAIL(S),,11719,521,$67.00 ,$67.00 ,$18.76 ,$61.31 ,$46.90 ,$56.08 ,$61.31 ,$61.31 ,$61.31 ,$24.69 ,$40.20 ,$20.10 ,$60.30 ,$50.25 ,$53.60 ,$55.61
Hoopeston Regional Hlth Center,17003,DSTRCTN PREMALG 2-14 EACH,,17003,521,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,17004,DSTRCTN PREMALG 15+ LSNS,,17004,521,"$1,010.00 ","$1,010.00 ",$282.80 ,$924.15 ,$707.00 ,$845.37 ,$924.15 ,$924.15 ,$924.15 ,$372.19 ,$606.00 ,$303.00 ,$909.00 ,$757.50 ,$808.00 ,$838.30
Hoopeston Regional Hlth Center,17111,DESTRUCTION BENIGN LESIONS 15 OR MORE,,17111,521,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,21930,EXCISION TUMOR SOFT TISSUE BACK/FLANK SUBQ <3CM,,21930,521,"$2,780.00 ","$2,780.00 ",$778.40 ,"$2,543.70 ","$1,946.00 ","$2,326.86 ","$2,543.70 ","$2,543.70 ","$2,543.70 ","$1,024.43 ","$1,668.00 ",$834.00 ,"$2,502.00 ","$2,085.00 ","$2,224.00 ","$2,307.40 "
Hoopeston Regional Hlth Center,59871,REMOVE CERCLAGE SUTURE,,59871,521,$830.00 ,$830.00 ,$232.40 ,$759.45 ,$581.00 ,$694.71 ,$759.45 ,$759.45 ,$759.45 ,$305.86 ,$498.00 ,$249.00 ,$747.00 ,$622.50 ,$664.00 ,$688.90
Hoopeston Regional Hlth Center,21935,RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK <5CM,,21935,521,"$7,480.00 ","$7,480.00 ","$2,094.40 ","$6,844.20 ","$5,236.00 ","$6,260.76 ","$6,844.20 ","$6,844.20 ","$6,844.20 ","$2,756.38 ","$4,488.00 ","$2,244.00 ","$6,732.00 ","$5,610.00 ","$5,984.00 ","$6,208.40 "
Hoopeston Regional Hlth Center,99374,SUPVJ PT HOME HEALTH AGENCY MO 15-29 MINUTES,,99374,521,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,99377,SUPERVISION HOSPICE PATIENT/MONTH 15-29 MIN,,99377,521,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,99378,SUPERVISION HOSPICE PATIENT/MONTH 30 MINUTES/>,,99378,521,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,99379,SUPERVISION NURS FACILITY PATIENT MO 15-29 MIN,,99379,521,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,99380,SUPERVISION NURS FACILITY PATIENT MONTH 30 MIN/>,,99380,521,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,G0101,CA screen;pelvic/breast exam,,G0101,521,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,G0105,Colorectal scrn; hi risk ind,,G0105,521,"$3,340.00 ","$3,340.00 ",$935.20 ,"$3,056.10 ","$2,338.00 ","$2,795.58 ","$3,056.10 ","$3,056.10 ","$3,056.10 ","$1,230.79 ","$2,004.00 ","$1,002.00 ","$3,006.00 ","$2,505.00 ","$2,672.00 ","$2,772.20 "
Hoopeston Regional Hlth Center,G0121,Colon ca scrn not hi rsk ind,,G0121,521,"$3,340.00 ","$3,340.00 ",$935.20 ,"$3,056.10 ","$2,338.00 ","$2,795.58 ","$3,056.10 ","$3,056.10 ","$3,056.10 ","$1,230.79 ","$2,004.00 ","$1,002.00 ","$3,006.00 ","$2,505.00 ","$2,672.00 ","$2,772.20 "
Hoopeston Regional Hlth Center,G0127,Trim nail(s),,G0127,521,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,10021,FINE NEEDLE ASP;W/O IMAGING GUIDANCE,,10021,521,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,11980,"IMPLANT,HORMONE,SUBCUTANEOUS",,11980,521,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,11981,INSERTION DRUG IMPLANT DEVICE,,11981,521,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,11982,REMOVAL DRUG IMPLANT DEVICE,,11982,521,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,11983,REMOVAL W/ REINSERT DRUG IMPLANT DEVICE,,11983,521,$940.00 ,$940.00 ,$263.20 ,$860.10 ,$658.00 ,$786.78 ,$860.10 ,$860.10 ,$860.10 ,$346.39 ,$564.00 ,$282.00 ,$846.00 ,$705.00 ,$752.00 ,$780.20
Hoopeston Regional Hlth Center,13102,"REP,SKIN,TRUNK,CMPLX,+5 CM/<",,13102,521,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,13122,"REP,SKIN,SCALP/EXTREM+5 CM/<",,13122,521,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,13133,"REPR,FACE,GENITAL,HAND,FT+5 CMCM/<",,13133,521,$990.00 ,$990.00 ,$277.20 ,$905.85 ,$693.00 ,$828.63 ,$905.85 ,$905.85 ,$905.85 ,$364.82 ,$594.00 ,$297.00 ,$891.00 ,$742.50 ,$792.00 ,$821.70
Hoopeston Regional Hlth Center,13153,"REPR,EYELID,NOSE,EAR,LIP+5 CM",,13153,521,"$1,320.00 ","$1,320.00 ",$369.60 ,"$1,207.80 ",$924.00 ,"$1,104.84 ","$1,207.80 ","$1,207.80 ","$1,207.80 ",$486.42 ,$792.00 ,$396.00 ,"$1,188.00 ",$990.00 ,"$1,056.00 ","$1,095.60 "
Hoopeston Regional Hlth Center,20526,INJECT CARPAL TUNNEL,,20526,521,$410.00 ,$410.00 ,$114.80 ,$375.15 ,$287.00 ,$343.17 ,$375.15 ,$375.15 ,$375.15 ,$151.09 ,$246.00 ,$123.00 ,$369.00 ,$307.50 ,$328.00 ,$340.30
Hoopeston Regional Hlth Center,20551,INJECT TENDON ORIGIN/INSERT,,20551,521,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,20552,"INJECT TRIGGER POINT, 1 OR 2",,20552,521,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,20553,"INJECT TRIGGER POINTS, > 3",,20553,521,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,20612,ASPIRAT/INJECTION GANGLION CYST(S),,20612,521,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,11600,"EXC SKIN MALIG <0.5 CM TRUNK,ARM,LEG",,11600,521,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,36556,INSERT NON-TUNNEL CV CATH,,36556,521,"$1,820.00 ","$1,820.00 ",$509.60 ,"$1,665.30 ","$1,274.00 ","$1,523.34 ","$1,665.30 ","$1,665.30 ","$1,665.30 ",$670.67 ,"$1,092.00 ",$546.00 ,"$1,638.00 ","$1,365.00 ","$1,456.00 ","$1,510.60 "
Hoopeston Regional Hlth Center,36569,INSERT PICC W/O SUB-Q PORT,,36569,521,"$1,890.00 ","$1,890.00 ",$529.20 ,"$1,729.35 ","$1,323.00 ","$1,581.93 ","$1,729.35 ","$1,729.35 ","$1,729.35 ",$696.47 ,"$1,134.00 ",$567.00 ,"$1,701.00 ","$1,417.50 ","$1,512.00 ","$1,568.70 "
Hoopeston Regional Hlth Center,38220,DIAGNOSTIC BONE MARROW ASPIRATIONS,,38220,521,$890.00 ,$890.00 ,$249.20 ,$814.35 ,$623.00 ,$744.93 ,$814.35 ,$814.35 ,$814.35 ,$327.97 ,$534.00 ,$267.00 ,$801.00 ,$667.50 ,$712.00 ,$738.70
Hoopeston Regional Hlth Center,38221,DIAGNOSTIC BONE MARROW BIOPSIES,,38221,521,$940.00 ,$940.00 ,$263.20 ,$860.10 ,$658.00 ,$786.78 ,$860.10 ,$860.10 ,$860.10 ,$346.39 ,$564.00 ,$282.00 ,$846.00 ,$705.00 ,$752.00 ,$780.20
Hoopeston Regional Hlth Center,11601,"EXC SKIN MALIG 0.6-1 CM TRUNK,ARM,LEG",,11601,521,$950.00 ,$950.00 ,$266.00 ,$869.25 ,$665.00 ,$795.15 ,$869.25 ,$869.25 ,$869.25 ,$350.08 ,$570.00 ,$285.00 ,$855.00 ,$712.50 ,$760.00 ,$788.50
Hoopeston Regional Hlth Center,51701,"INSERT,NON-INDWELLING BLADDER CATHETER",,51701,521,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,51702,"INSERT,TEMP INDWELLING BLAD CATH,SIMPLE",,51702,521,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,51703,"INSERT,TEMP INDWELLING BLAD CATH,COMP",,51703,521,"$1,190.00 ","$1,190.00 ",$333.20 ,"$1,088.85 ",$833.00 ,$996.03 ,"$1,088.85 ","$1,088.85 ","$1,088.85 ",$438.52 ,$714.00 ,$357.00 ,"$1,071.00 ",$892.50 ,$952.00 ,$987.70
Hoopeston Regional Hlth Center,51798,"MEAS,POST-VOID RES,US,NON-IMAGING",,51798,521,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,54162,"LYSIS/EXCIS,PENILE POSTCIRCUM ADHESIONS",,54162,521,"$1,190.00 ","$1,190.00 ",$333.20 ,"$1,088.85 ",$833.00 ,$996.03 ,"$1,088.85 ","$1,088.85 ","$1,088.85 ",$438.52 ,$714.00 ,$357.00 ,"$1,071.00 ",$892.50 ,$952.00 ,$987.70
Hoopeston Regional Hlth Center,56820,"COLPOSCOPY,VULVA",,56820,521,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,56821,"COLPOSCOPY,VULVA,W/BIOPSY(S)",,56821,521,$910.00 ,$910.00 ,$254.80 ,$832.65 ,$637.00 ,$761.67 ,$832.65 ,$832.65 ,$832.65 ,$335.34 ,$546.00 ,$273.00 ,$819.00 ,$682.50 ,$728.00 ,$755.30
Hoopeston Regional Hlth Center,57420,"COLPOSCOPY,ENTIRE VAGINA",,57420,521,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,57421,"COLPOSCOPY,ENTIRE VAGINA,W/BIOPSY(S)",,57421,521,$960.00 ,$960.00 ,$268.80 ,$878.40 ,$672.00 ,$803.52 ,$878.40 ,$878.40 ,$878.40 ,$353.76 ,$576.00 ,$288.00 ,$864.00 ,$720.00 ,$768.00 ,$796.80
Hoopeston Regional Hlth Center,57455,"COLPOSCOPY,CERVIX W/ADJ VAGINA,W/BX",,57455,521,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,57456,"COLPOSCOPY,CERVIX W/ADJ VAGINA, CURETTAG",,57456,521,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,57461,"COLPOSCOPY,CERVIX W/ADJ VAG,W/LOOP CONIZ",,57461,521,"$2,270.00 ","$2,270.00 ",$635.60 ,"$2,077.05 ","$1,589.00 ","$1,899.99 ","$2,077.05 ","$2,077.05 ","$2,077.05 ",$836.50 ,"$1,362.00 ",$681.00 ,"$2,043.00 ","$1,702.50 ","$1,816.00 ","$1,884.10 "
Hoopeston Regional Hlth Center,11602,"EXC SKIN MALIG 1.1-2 CM TRUNK,ARM,LEG",,11602,521,$990.00 ,$990.00 ,$277.20 ,$905.85 ,$693.00 ,$828.63 ,$905.85 ,$905.85 ,$905.85 ,$364.82 ,$594.00 ,$297.00 ,$891.00 ,$742.50 ,$792.00 ,$821.70
Hoopeston Regional Hlth Center,58555,"HYSTEROSCOPY,DX,SEP PROC",,58555,521,"$2,270.00 ","$2,270.00 ",$635.60 ,"$2,077.05 ","$1,589.00 ","$1,899.99 ","$2,077.05 ","$2,077.05 ","$2,077.05 ",$836.50 ,"$1,362.00 ",$681.00 ,"$2,043.00 ","$1,702.50 ","$1,816.00 ","$1,884.10 "
Hoopeston Regional Hlth Center,58558,"HYSTEROSCOPY,W/ENDO BX",,58558,521,"$3,290.00 ","$3,290.00 ",$921.20 ,"$3,010.35 ","$2,303.00 ","$2,753.73 ","$3,010.35 ","$3,010.35 ","$3,010.35 ","$1,212.37 ","$1,974.00 ",$987.00 ,"$2,961.00 ","$2,467.50 ","$2,632.00 ","$2,730.70 "
Hoopeston Regional Hlth Center,11603,"EXC SKIN MALIG 2.1-3 CM TRUNK,ARM,LEG",,11603,521,"$1,130.00 ","$1,130.00 ",$316.40 ,"$1,033.95 ",$791.00 ,$945.81 ,"$1,033.95 ","$1,033.95 ","$1,033.95 ",$416.41 ,$678.00 ,$339.00 ,"$1,017.00 ",$847.50 ,$904.00 ,$937.90
Hoopeston Regional Hlth Center,97802,"MED NUTR THER, 1ST, INDIV, EA 15 MIN",,97802,521,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,97803,"MED NUTR THER, SUBSQ, INDIV, EA 15 MIN",,97803,521,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,25608,"OPEN RX DISTAL RADIUS FX, INTRA-ARTICULAR, 2 FRAG",,25608,521,"$4,990.00 ","$4,990.00 ","$1,397.20 ","$4,565.85 ","$3,493.00 ","$4,176.63 ","$4,565.85 ","$4,565.85 ","$4,565.85 ","$1,838.82 ","$2,994.00 ","$1,497.00 ","$4,491.00 ","$3,742.50 ","$3,992.00 ","$4,141.70 "
Hoopeston Regional Hlth Center,22900,EXC TUMOR SOFT TISSUE ABDL WALL SUBFASCIAL <5CM,,22900,521,"$2,890.00 ","$2,890.00 ",$809.20 ,"$2,644.35 ","$2,023.00 ","$2,418.93 ","$2,644.35 ","$2,644.35 ","$2,644.35 ","$1,064.97 ","$1,734.00 ",$867.00 ,"$2,601.00 ","$2,167.50 ","$2,312.00 ","$2,398.70 "
Hoopeston Regional Hlth Center,11604,"EXC SKIN MALIG 3.1-4 CM TRUNK,ARM,LEG",,11604,521,"$1,420.00 ","$1,420.00 ",$397.60 ,"$1,299.30 ",$994.00 ,"$1,188.54 ","$1,299.30 ","$1,299.30 ","$1,299.30 ",$523.27 ,$852.00 ,$426.00 ,"$1,278.00 ","$1,065.00 ","$1,136.00 ","$1,178.60 "
Hoopeston Regional Hlth Center,23075,EXCISION TUMOR SOFT TISSUE SHOULDER SUBQ <3CM,,23075,521,"$1,960.00 ","$1,960.00 ",$548.80 ,"$1,793.40 ","$1,372.00 ","$1,640.52 ","$1,793.40 ","$1,793.40 ","$1,793.40 ",$722.26 ,"$1,176.00 ",$588.00 ,"$1,764.00 ","$1,470.00 ","$1,568.00 ","$1,626.80 "
Hoopeston Regional Hlth Center,23076,EXC TUMOR SOFT TISS SHOULDER SUBFASC <5CM,,23076,521,"$3,500.00 ","$3,500.00 ",$980.00 ,"$3,202.50 ","$2,450.00 ","$2,929.50 ","$3,202.50 ","$3,202.50 ","$3,202.50 ","$1,289.75 ","$2,100.00 ","$1,050.00 ","$3,150.00 ","$2,625.00 ","$2,800.00 ","$2,905.00 "
Hoopeston Regional Hlth Center,23077,RAD RESECTION TUMOR SOFT TISSUE SHOULDER <5CM,,23077,521,"$9,050.00 ","$9,050.00 ","$2,534.00 ","$8,280.75 ","$6,335.00 ","$7,574.85 ","$8,280.75 ","$8,280.75 ","$8,280.75 ","$3,334.93 ","$5,430.00 ","$2,715.00 ","$8,145.00 ","$6,787.50 ","$7,240.00 ","$7,511.50 "
Hoopeston Regional Hlth Center,11606,"EXC SKIN MALIG >4 CM TRUNK,ARM,LEG",,11606,521,"$1,920.00 ","$1,920.00 ",$537.60 ,"$1,756.80 ","$1,344.00 ","$1,607.04 ","$1,756.80 ","$1,756.80 ","$1,756.80 ",$707.52 ,"$1,152.00 ",$576.00 ,"$1,728.00 ","$1,440.00 ","$1,536.00 ","$1,593.60 "
Hoopeston Regional Hlth Center,58110,ENDOMET BIOPSY DONE W/COLPOSCOPY,,58110,521,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,58565,"HYSTEROSCOPY, STERILIZE W IMPLANTS",,58565,521,"$10,770.00 ","$10,770.00 ","$3,015.60 ","$9,854.55 ","$7,539.00 ","$9,014.49 ","$9,854.55 ","$9,854.55 ","$9,854.55 ","$3,968.75 ","$6,462.00 ","$3,231.00 ","$9,693.00 ","$8,077.50 ","$8,616.00 ","$8,939.10 "
Hoopeston Regional Hlth Center,11620,EXC SKIN MALIG <0.5 CM REMAINDER BODY,,11620,521,$840.00 ,$840.00 ,$235.20 ,$768.60 ,$588.00 ,$703.08 ,$768.60 ,$768.60 ,$768.60 ,$309.54 ,$504.00 ,$252.00 ,$756.00 ,$630.00 ,$672.00 ,$697.20
Hoopeston Regional Hlth Center,11621,EXC SKIN MALIG 0.6-1 CM REMAINDR BODY,,11621,521,$920.00 ,$920.00 ,$257.60 ,$841.80 ,$644.00 ,$770.04 ,$841.80 ,$841.80 ,$841.80 ,$339.02 ,$552.00 ,$276.00 ,$828.00 ,$690.00 ,$736.00 ,$763.60
Hoopeston Regional Hlth Center,97597,DEBRIDEMENT OPEN WOUND 20 SQ CM<,,97597,521,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,98960,"SELF-MGMT EDUC & TRAIN, 1 PT, EA 30 MIN",,98960,521,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,11622,EXC SKIN MALIG 1.1-2 CM REMAINDR BODY,,11622,521,"$1,110.00 ","$1,110.00 ",$310.80 ,"$1,015.65 ",$777.00 ,$929.07 ,"$1,015.65 ","$1,015.65 ","$1,015.65 ",$409.04 ,$666.00 ,$333.00 ,$999.00 ,$832.50 ,$888.00 ,$921.30
Hoopeston Regional Hlth Center,14301,"ADJ TISS XFER ANY AREA,30.1-60 SQCM",,14301,521,"$5,470.00 ","$5,470.00 ","$1,531.60 ","$5,005.05 ","$3,829.00 ","$4,578.39 ","$5,005.05 ","$5,005.05 ","$5,005.05 ","$2,015.70 ","$3,282.00 ","$1,641.00 ","$4,923.00 ","$4,102.50 ","$4,376.00 ","$4,540.10 "
Hoopeston Regional Hlth Center,14302,"ADJ TISS XFER ANY AREA,EA ADD 30.0 SQCM",,14302,521,"$1,410.00 ","$1,410.00 ",$394.80 ,"$1,290.15 ",$987.00 ,"$1,180.17 ","$1,290.15 ","$1,290.15 ","$1,290.15 ",$519.59 ,$846.00 ,$423.00 ,"$1,269.00 ","$1,057.50 ","$1,128.00 ","$1,170.30 "
Hoopeston Regional Hlth Center,21011,EXCISION TUMOR SOFT TISS FACE/SCALP SUBQ < 2CM,,21011,521,"$2,150.00 ","$2,150.00 ",$602.00 ,"$1,967.25 ","$1,505.00 ","$1,799.55 ","$1,967.25 ","$1,967.25 ","$1,967.25 ",$792.28 ,"$1,290.00 ",$645.00 ,"$1,935.00 ","$1,612.50 ","$1,720.00 ","$1,784.50 "
Hoopeston Regional Hlth Center,21013,EXC TUMOR SOFT TISS FACE&SCALP SUBFASCIAL < 2CM,,21013,521,"$3,310.00 ","$3,310.00 ",$926.80 ,"$3,028.65 ","$2,317.00 ","$2,770.47 ","$3,028.65 ","$3,028.65 ","$3,028.65 ","$1,219.74 ","$1,986.00 ",$993.00 ,"$2,979.00 ","$2,482.50 ","$2,648.00 ","$2,747.30 "
Hoopeston Regional Hlth Center,21016,RAD RESECTION TUMOR SOFT TISS FACE/SCALP 2 CM/>,,21016,521,"$6,690.00 ","$6,690.00 ","$1,873.20 ","$6,121.35 ","$4,683.00 ","$5,599.53 ","$6,121.35 ","$6,121.35 ","$6,121.35 ","$2,465.27 ","$4,014.00 ","$2,007.00 ","$6,021.00 ","$5,017.50 ","$5,352.00 ","$5,552.70 "
Hoopeston Regional Hlth Center,21558,RAD RESECT TUMOR SOFT TISS NECK/ANT THORAX 5CM/>,,21558,521,"$8,890.00 ","$8,890.00 ","$2,489.20 ","$8,134.35 ","$6,223.00 ","$7,440.93 ","$8,134.35 ","$8,134.35 ","$8,134.35 ","$3,275.97 ","$5,334.00 ","$2,667.00 ","$8,001.00 ","$6,667.50 ","$7,112.00 ","$7,378.70 "
Hoopeston Regional Hlth Center,21932,EXC TUMOR SOFT TISS BACK/FLANK SUBFASCIAL <5CM,,21932,521,"$4,530.00 ","$4,530.00 ","$1,268.40 ","$4,144.95 ","$3,171.00 ","$3,791.61 ","$4,144.95 ","$4,144.95 ","$4,144.95 ","$1,669.31 ","$2,718.00 ","$1,359.00 ","$4,077.00 ","$3,397.50 ","$3,624.00 ","$3,759.90 "
Hoopeston Regional Hlth Center,21936,RAD RESECTION TUMOR SOFT TISSUE BACK/FLANK 5CM/>,,21936,521,"$10,250.00 ","$10,250.00 ","$2,870.00 ","$9,378.75 ","$7,175.00 ","$8,579.25 ","$9,378.75 ","$9,378.75 ","$9,378.75 ","$3,777.13 ","$6,150.00 ","$3,075.00 ","$9,225.00 ","$7,687.50 ","$8,200.00 ","$8,507.50 "
Hoopeston Regional Hlth Center,22902,EXC TUMOR SOFT TISSUE ABDOMINAL WALL SUBQ <3CM,,22902,521,"$2,350.00 ","$2,350.00 ",$658.00 ,"$2,150.25 ","$1,645.00 ","$1,966.95 ","$2,150.25 ","$2,150.25 ","$2,150.25 ",$865.98 ,"$1,410.00 ",$705.00 ,"$2,115.00 ","$1,762.50 ","$1,880.00 ","$1,950.50 "
Hoopeston Regional Hlth Center,22904,RAD RESECTION TUMOR SOFT TISSUE ABDL WALL <5CM,,22904,521,"$6,150.00 ","$6,150.00 ","$1,722.00 ","$5,627.25 ","$4,305.00 ","$5,147.55 ","$5,627.25 ","$5,627.25 ","$5,627.25 ","$2,266.28 ","$3,690.00 ","$1,845.00 ","$5,535.00 ","$4,612.50 ","$4,920.00 ","$5,104.50 "
Hoopeston Regional Hlth Center,22905,RAD RESECTION TUMOR SOFT TISSUE ABDL WALL 5 CM/>,,22905,521,"$7,350.00 ","$7,350.00 ","$2,058.00 ","$6,725.25 ","$5,145.00 ","$6,151.95 ","$6,725.25 ","$6,725.25 ","$6,725.25 ","$2,708.48 ","$4,410.00 ","$2,205.00 ","$6,615.00 ","$5,512.50 ","$5,880.00 ","$6,100.50 "
Hoopeston Regional Hlth Center,23078,RAD RESECTION TUMOR SOFT TISSUE SHOULDER 5 CM/>,,23078,521,"$10,400.00 ","$10,400.00 ","$2,912.00 ","$9,516.00 ","$7,280.00 ","$8,704.80 ","$9,516.00 ","$9,516.00 ","$9,516.00 ","$3,832.40 ","$6,240.00 ","$3,120.00 ","$9,360.00 ","$7,800.00 ","$8,320.00 ","$8,632.00 "
Hoopeston Regional Hlth Center,24079,RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW 5CM/>,,24079,521,"$9,400.00 ","$9,400.00 ","$2,632.00 ","$8,601.00 ","$6,580.00 ","$7,867.80 ","$8,601.00 ","$8,601.00 ","$8,601.00 ","$3,463.90 ","$5,640.00 ","$2,820.00 ","$8,460.00 ","$7,050.00 ","$7,520.00 ","$7,802.00 "
Hoopeston Regional Hlth Center,25078,RAD RESCJ TUM SOFT TISSUE FOREARM&/WRIST 3 CM/>,,25078,521,"$8,760.00 ","$8,760.00 ","$2,452.80 ","$8,015.40 ","$6,132.00 ","$7,332.12 ","$8,015.40 ","$8,015.40 ","$8,015.40 ","$3,228.06 ","$5,256.00 ","$2,628.00 ","$7,884.00 ","$6,570.00 ","$7,008.00 ","$7,270.80 "
Hoopeston Regional Hlth Center,27059,RAD RESECTION TUMOR SOFT TISS PELVIS&HIP 5 CM/>,,27059,521,"$13,410.00 ","$13,410.00 ","$3,754.80 ","$12,270.15 ","$9,387.00 ","$11,224.17 ","$12,270.15 ","$12,270.15 ","$12,270.15 ","$4,941.59 ","$8,046.00 ","$4,023.00 ","$12,069.00 ","$10,057.50 ","$10,728.00 ","$11,130.30 "
Hoopeston Regional Hlth Center,27364,RAD RESECTION TUMOR SOFT TIS THIGH/KNEE 5 CM/>,,27364,521,"$12,100.00 ","$12,100.00 ","$3,388.00 ","$11,071.50 ","$8,470.00 ","$10,127.70 ","$11,071.50 ","$11,071.50 ","$11,071.50 ","$4,458.85 ","$7,260.00 ","$3,630.00 ","$10,890.00 ","$9,075.00 ","$9,680.00 ","$10,043.00 "
Hoopeston Regional Hlth Center,27616,RAD RESECTION TUMOR SOFT TISSUE LEG/ANKLE 5 CM/>,,27616,521,"$9,600.00 ","$9,600.00 ","$2,688.00 ","$8,784.00 ","$6,720.00 ","$8,035.20 ","$8,784.00 ","$8,784.00 ","$8,784.00 ","$3,537.60 ","$5,760.00 ","$2,880.00 ","$8,640.00 ","$7,200.00 ","$7,680.00 ","$7,968.00 "
Hoopeston Regional Hlth Center,11623,EXC SKIN MALIG 2.1-3 CM REMAINDR BODY,,11623,521,"$1,340.00 ","$1,340.00 ",$375.20 ,"$1,226.10 ",$938.00 ,"$1,121.58 ","$1,226.10 ","$1,226.10 ","$1,226.10 ",$493.79 ,$804.00 ,$402.00 ,"$1,206.00 ","$1,005.00 ","$1,072.00 ","$1,112.20 "
Hoopeston Regional Hlth Center,36591,COLLECT BLOOD FROM IMPLANT VENOUS ACCESS DEVICE,,36591,521,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,36592,COLLECT BLOOD FROM CATHETER VENOUS NOS,,36592,521,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,36593,DECLOT BY THROMBOLYTIC AGENT IMPLANT DEVICE/CATH,,36593,521,$320.00 ,$320.00 ,$89.60 ,$292.80 ,$224.00 ,$267.84 ,$292.80 ,$292.80 ,$292.80 ,$117.92 ,$192.00 ,$96.00 ,$288.00 ,$240.00 ,$256.00 ,$265.60
Hoopeston Regional Hlth Center,49411,"PLACE INTERST RAD THER GUIDE, PERC,INTRAABD/INTRAPELV/RETROPER,1+",,49411,521,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,51727,COMPLEX CYSTOMETROGRAM URETHRAL PRESS PROFILE,,51727,521,"$1,470.00 ","$1,470.00 ",$411.60 ,"$1,345.05 ","$1,029.00 ","$1,230.39 ","$1,345.05 ","$1,345.05 ","$1,345.05 ",$541.70 ,$882.00 ,$441.00 ,"$1,323.00 ","$1,102.50 ","$1,176.00 ","$1,220.10 "
Hoopeston Regional Hlth Center,64632,DESTRUCT BY NEURO AGENT; PLANTAR DIGITAL NERVE,,64632,521,$680.00 ,$680.00 ,$190.40 ,$622.20 ,$476.00 ,$569.16 ,$622.20 ,$622.20 ,$622.20 ,$250.58 ,$408.00 ,$204.00 ,$612.00 ,$510.00 ,$544.00 ,$564.40
Hoopeston Regional Hlth Center,11624,EXC SKIN MALIG 3.1-4 CM REMAINDR BODY,,11624,521,"$1,610.00 ","$1,610.00 ",$450.80 ,"$1,473.15 ","$1,127.00 ","$1,347.57 ","$1,473.15 ","$1,473.15 ","$1,473.15 ",$593.29 ,$966.00 ,$483.00 ,"$1,449.00 ","$1,207.50 ","$1,288.00 ","$1,336.30 "
Hoopeston Regional Hlth Center,23500,CLOSED RX CLAVICLE FRACTURE,,23500,521,"$1,260.00 ","$1,260.00 ",$352.80 ,"$1,152.90 ",$882.00 ,"$1,054.62 ","$1,152.90 ","$1,152.90 ","$1,152.90 ",$464.31 ,$756.00 ,$378.00 ,"$1,134.00 ",$945.00 ,"$1,008.00 ","$1,045.80 "
Hoopeston Regional Hlth Center,96372,"INJECTION,THERAP/PROPH/DIAGNOST, IM OR SUBCUT",,96372,521,$86.00 ,$86.00 ,$24.08 ,$78.69 ,$60.20 ,$71.98 ,$78.69 ,$78.69 ,$78.69 ,$31.69 ,$51.60 ,$25.80 ,$77.40 ,$64.50 ,$68.80 ,$71.38
Hoopeston Regional Hlth Center,96373,"INJECTION,THERAP/PROPH/DIAGNOST, INTRA-ARTERIAL",,96373,521,$93.00 ,$93.00 ,$26.04 ,$85.10 ,$65.10 ,$77.84 ,$85.10 ,$85.10 ,$85.10 ,$34.27 ,$55.80 ,$27.90 ,$83.70 ,$69.75 ,$74.40 ,$77.19
Hoopeston Regional Hlth Center,96374,"INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, INITIAL DRUG",,96374,521,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,96375,"INJECTION,THERAP/PROPH/DIAGNOST, IV PUSH, EA ADD, NEW DRUG",,96375,521,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,98966,NONPHYSICIAN TELEPHONE ASSESSMENT 5-10 MIN,,98966,521,$93.00 ,$93.00 ,$26.04 ,$85.10 ,$65.10 ,$77.84 ,$85.10 ,$85.10 ,$85.10 ,$34.27 ,$55.80 ,$27.90 ,$83.70 ,$69.75 ,$74.40 ,$77.19
Hoopeston Regional Hlth Center,98967,NONPHYSICIAN TELEPHONE ASSESSMENT 11-20 MIN,,98967,521,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,11626,EXC SKIN MALIG >4 CM REMAINDR BODY,,11626,521,"$2,040.00 ","$2,040.00 ",$571.20 ,"$1,866.60 ","$1,428.00 ","$1,707.48 ","$1,866.60 ","$1,866.60 ","$1,866.60 ",$751.74 ,"$1,224.00 ",$612.00 ,"$1,836.00 ","$1,530.00 ","$1,632.00 ","$1,693.20 "
Hoopeston Regional Hlth Center,98968,NONPHYSICIAN TELEPHONE ASSESSMENT 21-30 MIN,,98968,521,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,99406,TOBACCO USE CESSATION INTERMEDIATE 3-10 MINUTES,,99406,521,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,99407,TOBACCO USE CESSATION INTENSIVE >10 MINUTES,,99407,521,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,99408,ALCOHOL/SUBSTANCE SCREEN & INTERVEN 15-30 MIN,,99408,521,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,99441,PHYS/QHP TELEPHONE EVALUATION 5-10 MIN,,99441,521,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,99442,PHYS/QHP TELEPHONE EVALUATION 11-20 MIN,,99442,521,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,99443,PHYS/QHP TELEPHONE EVALUATION 21-30 MIN,,99443,521,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,23600,CLOSED RX PROX HUMERUS FRACTURE,,23600,521,"$1,910.00 ","$1,910.00 ",$534.80 ,"$1,747.65 ","$1,337.00 ","$1,598.67 ","$1,747.65 ","$1,747.65 ","$1,747.65 ",$703.84 ,"$1,146.00 ",$573.00 ,"$1,719.00 ","$1,432.50 ","$1,528.00 ","$1,585.30 "
Hoopeston Regional Hlth Center,G0102,Prostate ca screening; dre,,G0102,521,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,G0168,Wound closure by adhesive,,G0168,521,$540.00 ,$540.00 ,$151.20 ,$494.10 ,$378.00 ,$451.98 ,$494.10 ,$494.10 ,$494.10 ,$198.99 ,$324.00 ,$162.00 ,$486.00 ,$405.00 ,$432.00 ,$448.20
Hoopeston Regional Hlth Center,G0179,MD recertification HHA PT,,G0179,521,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,G0180,MD certification HHA patient,,G0180,521,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,G0402,Initial preventive exam,,G0402,521,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,11640,"EXC SKIN MALIG <0.5 CM FACE,FACIAL",,11640,521,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,23650,CLOSED RX SHLDR DISLOCATION,,23650,521,"$1,710.00 ","$1,710.00 ",$478.80 ,"$1,564.65 ","$1,197.00 ","$1,431.27 ","$1,564.65 ","$1,564.65 ","$1,564.65 ",$630.14 ,"$1,026.00 ",$513.00 ,"$1,539.00 ","$1,282.50 ","$1,368.00 ","$1,419.30 "
Hoopeston Regional Hlth Center,11641,"EXC SKIN MALIG 0.6-1CM FACE,FACIAL",,11641,521,"$1,140.00 ","$1,140.00 ",$319.20 ,"$1,043.10 ",$798.00 ,$954.18 ,"$1,043.10 ","$1,043.10 ","$1,043.10 ",$420.09 ,$684.00 ,$342.00 ,"$1,026.00 ",$855.00 ,$912.00 ,$946.20
Hoopeston Regional Hlth Center,10120,REMOVE FOREIGN BODY SIMPLE,,10120,521,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,11642,"EXC SKIN MALIG 1.1-2 CM FACE,FACIAL",,11642,521,"$1,310.00 ","$1,310.00 ",$366.80 ,"$1,198.65 ",$917.00 ,"$1,096.47 ","$1,198.65 ","$1,198.65 ","$1,198.65 ",$482.74 ,$786.00 ,$393.00 ,"$1,179.00 ",$982.50 ,"$1,048.00 ","$1,087.30 "
Hoopeston Regional Hlth Center,24075,EXC TUMOR SOFT TISS UPPER ARM/ELBOW SUBQ <3CM,,24075,521,"$3,230.00 ","$3,230.00 ",$904.40 ,"$2,955.45 ","$2,261.00 ","$2,703.51 ","$2,955.45 ","$2,955.45 ","$2,955.45 ","$1,190.26 ","$1,938.00 ",$969.00 ,"$2,907.00 ","$2,422.50 ","$2,584.00 ","$2,680.90 "
Hoopeston Regional Hlth Center,24076,EXC TUMOR SOFT TISS UPR ARM/ELBOW SUBFASC <5CM,,24076,521,"$3,620.00 ","$3,620.00 ","$1,013.60 ","$3,312.30 ","$2,534.00 ","$3,029.94 ","$3,312.30 ","$3,312.30 ","$3,312.30 ","$1,333.97 ","$2,172.00 ","$1,086.00 ","$3,258.00 ","$2,715.00 ","$2,896.00 ","$3,004.60 "
Hoopeston Regional Hlth Center,24077,RAD RESECT TUMOR SOFT TISS UPPER ARM/ELBOW <5CM,,24077,521,"$6,940.00 ","$6,940.00 ","$1,943.20 ","$6,350.10 ","$4,858.00 ","$5,808.78 ","$6,350.10 ","$6,350.10 ","$6,350.10 ","$2,557.39 ","$4,164.00 ","$2,082.00 ","$6,246.00 ","$5,205.00 ","$5,552.00 ","$5,760.20 "
Hoopeston Regional Hlth Center,11643,"EXC SKIN MALIG 2.1-3 CM FACE,FACIAL",,11643,521,"$1,530.00 ","$1,530.00 ",$428.40 ,"$1,399.95 ","$1,071.00 ","$1,280.61 ","$1,399.95 ","$1,399.95 ","$1,399.95 ",$563.81 ,$918.00 ,$459.00 ,"$1,377.00 ","$1,147.50 ","$1,224.00 ","$1,269.90 "
Hoopeston Regional Hlth Center,11644,"EXC SKIN MALIG 3.1-4 CM FACE,FACIAL",,11644,521,"$1,870.00 ","$1,870.00 ",$523.60 ,"$1,711.05 ","$1,309.00 ","$1,565.19 ","$1,711.05 ","$1,711.05 ","$1,711.05 ",$689.10 ,"$1,122.00 ",$561.00 ,"$1,683.00 ","$1,402.50 ","$1,496.00 ","$1,552.10 "
Hoopeston Regional Hlth Center,11646,"EXC SKIN MALIG >4 CM FACE,FACIAL",,11646,521,"$2,510.00 ","$2,510.00 ",$702.80 ,"$2,296.65 ","$1,757.00 ","$2,100.87 ","$2,296.65 ","$2,296.65 ","$2,296.65 ",$924.94 ,"$1,506.00 ",$753.00 ,"$2,259.00 ","$1,882.50 ","$2,008.00 ","$2,083.30 "
Hoopeston Regional Hlth Center,11730,REMOVAL OF NAIL PLATE,,11730,521,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,11732,REMOVE ADDITIONAL NAIL PLATE,,11732,521,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,11740,DRAIN BLOOD FROM UNDER NAIL,,11740,521,$195.00 ,$195.00 ,$54.60 ,$178.43 ,$136.50 ,$163.22 ,$178.43 ,$178.43 ,$178.43 ,$71.86 ,$117.00 ,$58.50 ,$175.50 ,$146.25 ,$156.00 ,$161.85
Hoopeston Regional Hlth Center,11750,REMOVAL OF NAIL BED,,11750,521,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,24640,"CLOSED RX RADIAL HEAD DISLOC,CHILD",,24640,521,$790.00 ,$790.00 ,$221.20 ,$722.85 ,$553.00 ,$661.23 ,$722.85 ,$722.85 ,$722.85 ,$291.12 ,$474.00 ,$237.00 ,$711.00 ,$592.50 ,$632.00 ,$655.70
Hoopeston Regional Hlth Center,24650,CLOSED RX RADIAL HEAD/NECK FX,,24650,521,"$1,390.00 ","$1,390.00 ",$389.20 ,"$1,271.85 ",$973.00 ,"$1,163.43 ","$1,271.85 ","$1,271.85 ","$1,271.85 ",$512.22 ,$834.00 ,$417.00 ,"$1,251.00 ","$1,042.50 ","$1,112.00 ","$1,153.70 "
Hoopeston Regional Hlth Center,10121,REMOVE FOREIGN BODY COMPLIC,,10121,521,"$1,260.00 ","$1,260.00 ",$352.80 ,"$1,152.90 ",$882.00 ,"$1,054.62 ","$1,152.90 ","$1,152.90 ","$1,152.90 ",$464.31 ,$756.00 ,$378.00 ,"$1,134.00 ",$945.00 ,"$1,008.00 ","$1,045.80 "
Hoopeston Regional Hlth Center,25075,EXC TUMOR SOFT TISSUE FOREARM &/WRIST SUBQ <3CM,,25075,521,"$2,680.00 ","$2,680.00 ",$750.40 ,"$2,452.20 ","$1,876.00 ","$2,243.16 ","$2,452.20 ","$2,452.20 ","$2,452.20 ",$987.58 ,"$1,608.00 ",$804.00 ,"$2,412.00 ","$2,010.00 ","$2,144.00 ","$2,224.40 "
Hoopeston Regional Hlth Center,25076,EXC TUMOR SOFT TISS FOREARM&/WRIST SUBFASC <3CM,,25076,521,"$4,350.00 ","$4,350.00 ","$1,218.00 ","$3,980.25 ","$3,045.00 ","$3,640.95 ","$3,980.25 ","$3,980.25 ","$3,980.25 ","$1,602.98 ","$2,610.00 ","$1,305.00 ","$3,915.00 ","$3,262.50 ","$3,480.00 ","$3,610.50 "
Hoopeston Regional Hlth Center,25077,RAD RESECT TUMOR SOFT TISS FOREARM&/WRIST <3 CM,,25077,521,"$7,510.00 ","$7,510.00 ","$2,102.80 ","$6,871.65 ","$5,257.00 ","$6,285.87 ","$6,871.65 ","$6,871.65 ","$6,871.65 ","$2,767.44 ","$4,506.00 ","$2,253.00 ","$6,759.00 ","$5,632.50 ","$6,008.00 ","$6,233.30 "
Hoopeston Regional Hlth Center,11765,"EXCISION OF NAIL FOLD, TOE",,11765,521,$590.00 ,$590.00 ,$165.20 ,$539.85 ,$413.00 ,$493.83 ,$539.85 ,$539.85 ,$539.85 ,$217.42 ,$354.00 ,$177.00 ,$531.00 ,$442.50 ,$472.00 ,$489.70
Hoopeston Regional Hlth Center,11045,"DEBRIDEMENT, SKIN, SUB-Q TISSUE,EACH ADD 20 SQ CM",,11045,521,$215.00 ,$215.00 ,$60.20 ,$196.73 ,$150.50 ,$179.96 ,$196.73 ,$196.73 ,$196.73 ,$79.23 ,$129.00 ,$64.50 ,$193.50 ,$161.25 ,$172.00 ,$178.45
Hoopeston Regional Hlth Center,11047,"DEBRIDEMENT, SKIN, SUB-Q TISSUE,MUSCLE,BONE,EACH ADD 20 SQ CM",,11047,521,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,15271,APP SKN SUB GRFT T/A/L AREA/<100SCM /<1ST 25 SCM,,15271,521,$960.00 ,$960.00 ,$268.80 ,$878.40 ,$672.00 ,$803.52 ,$878.40 ,$878.40 ,$878.40 ,$353.76 ,$576.00 ,$288.00 ,$864.00 ,$720.00 ,$768.00 ,$796.80
Hoopeston Regional Hlth Center,15272,APP SKN SUB GRFT T/A/L AREA/<100SCM EA ADL 25SCM,,15272,521,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,20527,INJECTION ENZYME PALMAR FASCIAL CORD,,20527,521,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,49082,ABDOM PARACENTESIS DX/THER W/O IMAGING GUIDANCE,,49082,521,$980.00 ,$980.00 ,$274.40 ,$896.70 ,$686.00 ,$820.26 ,$896.70 ,$896.70 ,$896.70 ,$361.13 ,$588.00 ,$294.00 ,$882.00 ,$735.00 ,$784.00 ,$813.40
Hoopeston Regional Hlth Center,49083,ABDOM PARACENTESIS DX/THER W IMAGING GUIDANCE,,49083,521,"$1,790.00 ","$1,790.00 ",$501.20 ,"$1,637.85 ","$1,253.00 ","$1,498.23 ","$1,637.85 ","$1,637.85 ","$1,637.85 ",$659.62 ,"$1,074.00 ",$537.00 ,"$1,611.00 ","$1,342.50 ","$1,432.00 ","$1,485.70 "
Hoopeston Regional Hlth Center,G0436,Tobacco-use counsel 3-10 min,,G0436,521,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,G0437,Tobacco-use counsel>10min,,G0437,521,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,G0438,"PPPS, initial visit",,G0438,521,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,G0439,"PPPS, subseq visit",,G0439,521,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,G0442,Annual alcohol screen 15 min,,G0442,521,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,G0443,Brief alcohol misuse counsel,,G0443,521,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,G0444,Depression screen annual,,G0444,521,$54.00 ,$54.00 ,$15.12 ,$49.41 ,$37.80 ,$45.20 ,$49.41 ,$49.41 ,$49.41 ,$19.90 ,$32.40 ,$16.20 ,$48.60 ,$40.50 ,$43.20 ,$44.82
Hoopeston Regional Hlth Center,G0447,Behavior counsel obesity 15m,,G0447,521,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,G0446,Intens behave ther cardio dx,,G0446,521,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,11900,"INJECTION INTO SKIN LESIONS, UP TO 7",,11900,521,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,11901,"INJECTION INTO SKIN LESIONS, 8 OR MORE",,11901,521,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,11920,CORRECT SKIN COLR DEFCT <6 SQCM,,11920,521,"$1,740.00 ","$1,740.00 ",$487.20 ,"$1,592.10 ","$1,218.00 ","$1,456.38 ","$1,592.10 ","$1,592.10 ","$1,592.10 ",$641.19 ,"$1,044.00 ",$522.00 ,"$1,566.00 ","$1,305.00 ","$1,392.00 ","$1,444.20 "
Hoopeston Regional Hlth Center,25500,CLOSED RX RADIAL SHAFT FX,,25500,521,"$1,480.00 ","$1,480.00 ",$414.40 ,"$1,354.20 ","$1,036.00 ","$1,238.76 ","$1,354.20 ","$1,354.20 ","$1,354.20 ",$545.38 ,$888.00 ,$444.00 ,"$1,332.00 ","$1,110.00 ","$1,184.00 ","$1,228.40 "
Hoopeston Regional Hlth Center,11921,CORRECT SKIN COLR DEFCT 6.1-20 SQCM,,11921,521,"$2,670.00 ","$2,670.00 ",$747.60 ,"$2,443.05 ","$1,869.00 ","$2,234.79 ","$2,443.05 ","$2,443.05 ","$2,443.05 ",$983.90 ,"$1,602.00 ",$801.00 ,"$2,403.00 ","$2,002.50 ","$2,136.00 ","$2,216.10 "
Hoopeston Regional Hlth Center,10140,DRAINAGE OF HEMATOMA/FLUID,,10140,521,$750.00 ,$750.00 ,$210.00 ,$686.25 ,$525.00 ,$627.75 ,$686.25 ,$686.25 ,$686.25 ,$276.38 ,$450.00 ,$225.00 ,$675.00 ,$562.50 ,$600.00 ,$622.50
Hoopeston Regional Hlth Center,90833,MEDICAL SERVICE,,90833,521,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,90836,MEDICAL SERVICE,,90836,521,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,90838,MEDICAL SERVICE,,90838,521,$345.00 ,$345.00 ,$96.60 ,$315.68 ,$241.50 ,$288.77 ,$315.68 ,$315.68 ,$315.68 ,$127.13 ,$207.00 ,$103.50 ,$310.50 ,$258.75 ,$276.00 ,$286.35
Hoopeston Regional Hlth Center,25600,CLOSED RX DIST RAD/ULNA FX,,25600,521,"$1,580.00 ","$1,580.00 ",$442.40 ,"$1,445.70 ","$1,106.00 ","$1,322.46 ","$1,445.70 ","$1,445.70 ","$1,445.70 ",$582.23 ,$948.00 ,$474.00 ,"$1,422.00 ","$1,185.00 ","$1,264.00 ","$1,311.40 "
Hoopeston Regional Hlth Center,99495,TRANSITIONAL CARE MANAGE SERVICE 14 DAY DISCHRGE,,99495,521,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,99496,TRANSITIONAL CARE MANAGE SERVICE 7 DAY DISCHARGE,,99496,521,$780.00 ,$780.00 ,$218.40 ,$713.70 ,$546.00 ,$652.86 ,$713.70 ,$713.70 ,$713.70 ,$287.43 ,$468.00 ,$234.00 ,$702.00 ,$585.00 ,$624.00 ,$647.40
Hoopeston Regional Hlth Center,69209,REMOVAL IMPACTED CERUMEN IRRIGATION/LVG UNILAT,,69209,521,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,11950,FILL CONTOUR DEFCT <1CC,,11950,521,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,G0296,VISIT TO DETERM LDCT ELIG,,G0296,521,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,11951,FILL CONTOUR DEFCT 1.1-5CC,,11951,521,$810.00 ,$810.00 ,$226.80 ,$741.15 ,$567.00 ,$677.97 ,$741.15 ,$741.15 ,$741.15 ,$298.49 ,$486.00 ,$243.00 ,$729.00 ,$607.50 ,$648.00 ,$672.30
Hoopeston Regional Hlth Center,26010,"DRAIN FINGER ABSCESS,SIMPLE",,26010,521,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,7999915,"Pr Special Reports, Legal Purposes",,99080,521,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,26115,EXC TUM/VASC MAL SFT TISS HAND/FNGR SUBQ <1.5CM,,26115,521,"$3,000.00 ","$3,000.00 ",$840.00 ,"$2,745.00 ","$2,100.00 ","$2,511.00 ","$2,745.00 ","$2,745.00 ","$2,745.00 ","$1,105.50 ","$1,800.00 ",$900.00 ,"$2,700.00 ","$2,250.00 ","$2,400.00 ","$2,490.00 "
Hoopeston Regional Hlth Center,26116,EXC TUM/VAS MAL SFT TIS HAND/FNGR SUBFASC<1.5CM,,26116,521,"$3,810.00 ","$3,810.00 ","$1,066.80 ","$3,486.15 ","$2,667.00 ","$3,188.97 ","$3,486.15 ","$3,486.15 ","$3,486.15 ","$1,403.99 ","$2,286.00 ","$1,143.00 ","$3,429.00 ","$2,857.50 ","$3,048.00 ","$3,162.30 "
Hoopeston Regional Hlth Center,26117,RAD RESECT TUMOR SOFT TISSUE HAND/FINGER <3CM,,26117,521,"$6,140.00 ","$6,140.00 ","$1,719.20 ","$5,618.10 ","$4,298.00 ","$5,139.18 ","$5,618.10 ","$5,618.10 ","$5,618.10 ","$2,262.59 ","$3,684.00 ","$1,842.00 ","$5,526.00 ","$4,605.00 ","$4,912.00 ","$5,096.20 "
Hoopeston Regional Hlth Center,11976,REMOVAL OF CONTRACEPTIVE CAPSUL,,11976,521,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,10160,PUNCTURE DRAINAGE OF LESION,,10160,521,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,99341,HOME VISIT NEW PATIENT LEVEL 1,,99341,522,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,99342,HOME VISIT NEW PATIENT LEVEL 2,,99342,522,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,99343,HOME VST NEW PATIENT LEVEL 3,,99343,522,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,99344,HOME VISIT NEW PATIENT LEVEL 4,,99344,522,$455.00 ,$455.00 ,$127.40 ,$416.33 ,$318.50 ,$380.84 ,$416.33 ,$416.33 ,$416.33 ,$167.67 ,$273.00 ,$136.50 ,$409.50 ,$341.25 ,$364.00 ,$377.65
Hoopeston Regional Hlth Center,99345,HOME VISIT NEW PT LEVEL 5,,99345,522,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,99347,HOME VISIT EST PT LEVEL 1,,99347,522,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,99348,HOME VISIT EST PT LEVEL 2,,99348,522,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,99349,HOME VISIT EST PT LEVEL 3,,99349,522,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,99350,HOME VST EST PT LEVEL 4,,99350,522,$470.00 ,$470.00 ,$131.60 ,$430.05 ,$329.00 ,$393.39 ,$430.05 ,$430.05 ,$430.05 ,$173.20 ,$282.00 ,$141.00 ,$423.00 ,$352.50 ,$376.00 ,$390.10
Hoopeston Regional Hlth Center,99324,DOMICIL/REST HOME NEW PT VISIT LEVEL 1,,99324,522,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,99325,DOMICIL/REST HOME NEW PT VISIT LEVEL 2,,99325,522,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,99326,DOMICIL/REST HOME NEW PT LEVEL 3,,99326,522,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,99327,DOMICIL/REST HOME NEW PT VISIT LEVEL 4,,99327,522,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,99328,DOM/R-HOME E/M NEW PT LEVEL 5,,99328,522,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,99334,DOM/R-HOME E/M EST PT LEVEL 1,,99334,522,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,99335,DOM/R-HOME E/M EST PT LEVEL 2,,99335,522,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,99336,DOM/R-HOME E/M EST PT LEVEL 3,,99336,522,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,99337,DOM/R-HOME E/M EST PT LEVEL 4,,99337,522,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,99315,"NURSING FAC DISCHRGE DAY,1-30 MIN",,99315,524,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,99316,"NURSING FAC DISCHRGE DAY,MORE 30 MIN",,99316,524,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,99304,INITIAL NURSING FACILITY CARE/DAY LEVEL 1,,99304,524,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,99305,INITIAL NURSING FACILITY CARE/DAY LEVEL 2,,99305,524,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,99306,INITIAL NURSING FACILITY CARE/DAY LEVEL 3,,99306,524,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,99307,SBSQ NURSING FACILITY CARE/DAY LEVEL 1,,99307,524,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,99308,SBSQ NURSING FACIL CARE/DAY LEVEL 2,,99308,524,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,99309,SBSQ NURSING FACIL CARE/DAY LEVEL 3,,99309,524,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,99310,SBSQ NURS FACIL CARE/DAY LEVEL 4,,99310,524,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,99318,E/M ANNUAL NURSING FACILITY ASSESS,,99318,524,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,98925,"OSTEOPATHIC MANIP,1-2 BODY REGN",,98925,530,$135.00 ,$135.00 ,$37.80 ,$123.53 ,$94.50 ,$113.00 ,$123.53 ,$123.53 ,$123.53 ,$49.75 ,$81.00 ,$40.50 ,$121.50 ,$101.25 ,$108.00 ,$112.05
Hoopeston Regional Hlth Center,98926,"OSTEOPATHIC MANIP,3-4 BODY REGN",,98926,530,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,98927,"OSTEOPATHIC MANIP,5-6 BODY REGN",,98927,530,$215.00 ,$215.00 ,$60.20 ,$196.73 ,$150.50 ,$179.96 ,$196.73 ,$196.73 ,$196.73 ,$79.23 ,$129.00 ,$64.50 ,$193.50 ,$161.25 ,$172.00 ,$178.45
Hoopeston Regional Hlth Center,98928,"OSTEOPATHIC MANIP,7-8 BODY REGN",,98928,530,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,98929,"OSTEOPATHIC MANIP,9-10 BODY REGN",,98929,530,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,9910420,AMBULANCE WAIT TIME/HALF HOUR INCREMENTS,,A0420,540,$42.00 ,$42.00 ,$11.76 ,$38.43 ,$29.40 ,$35.15 ,$38.43 ,$38.43 ,$38.43 ,$15.48 ,$25.20 ,$12.60 ,$37.80 ,$31.50 ,$33.60 ,$34.86
Hoopeston Regional Hlth Center,9910422,AMBULANCE OXYGEN,,A0422,540,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,9910425,AMBULANCE MILES 18 AND OVER (PER MILE),,A0425,540,$18.00 ,$18.00 ,$5.04 ,$16.47 ,$12.60 ,$15.07 ,$16.47 ,$16.47 ,$16.47 ,$6.63 ,$10.80 ,$5.40 ,$16.20 ,$13.50 ,$14.40 ,$14.94
Hoopeston Regional Hlth Center,9911425,AMBULANCE MILES 1-17 (PER MILE),,A0425,540,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9910426,AMBULANCE ALS-1 NON-EMERGENT,,A0426,540,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,9910427,AMBULANCE ALS-1 EMERGENT,,A0427,540,"$1,010.00 ","$1,010.00 ",$282.80 ,$924.15 ,$707.00 ,$845.37 ,$924.15 ,$924.15 ,$924.15 ,$372.19 ,$606.00 ,$303.00 ,$909.00 ,$757.50 ,$808.00 ,$838.30
Hoopeston Regional Hlth Center,9919428,AMBULANCE BLS NON-EMERGENT,,A0428,540,$485.00 ,$485.00 ,$135.80 ,$443.78 ,$339.50 ,$405.95 ,$443.78 ,$443.78 ,$443.78 ,$178.72 ,$291.00 ,$145.50 ,$436.50 ,$363.75 ,$388.00 ,$402.55
Hoopeston Regional Hlth Center,9910429,AMBULANCE BLS-EMERGENT,,A0429,540,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,9910432,AMBULANCE INTERCEPT,,A0432,540,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,9910433,AMBULANCE ALS-2,,A0433,540,"$1,200.00 ","$1,200.00 ",$336.00 ,"$1,098.00 ",$840.00 ,"$1,004.40 ","$1,098.00 ","$1,098.00 ","$1,098.00 ",$442.20 ,$720.00 ,$360.00 ,"$1,080.00 ",$900.00 ,$960.00 ,$996.00
Hoopeston Regional Hlth Center,9910434,AMBULANCE SCT (SPECIAL CARE WITH NURSE),,A0434,540,"$1,240.00 ","$1,240.00 ",$347.20 ,"$1,134.60 ",$868.00 ,"$1,037.88 ","$1,134.60 ","$1,134.60 ","$1,134.60 ",$456.94 ,$744.00 ,$372.00 ,"$1,116.00 ",$930.00 ,$992.00 ,"$1,029.20 "
Hoopeston Regional Hlth Center,9470336,MRI TMJ,,70336,610,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,9470540,MRI NECK W/O CONT,,70540,610,"$2,800.00 ","$2,800.00 ",$784.00 ,"$2,562.00 ","$1,960.00 ","$2,343.60 ","$2,562.00 ","$2,562.00 ","$2,562.00 ","$1,031.80 ","$1,680.00 ",$840.00 ,"$2,520.00 ","$2,100.00 ","$2,240.00 ","$2,324.00 "
Hoopeston Regional Hlth Center,9470542,MRI NECK W/ CONTRAST,,70542,610,"$2,930.00 ","$2,930.00 ",$820.40 ,"$2,680.95 ","$2,051.00 ","$2,452.41 ","$2,680.95 ","$2,680.95 ","$2,680.95 ","$1,079.71 ","$1,758.00 ",$879.00 ,"$2,637.00 ","$2,197.50 ","$2,344.00 ","$2,431.90 "
Hoopeston Regional Hlth Center,9471550,MRI CHEST WO CONT,,71550,610,"$2,470.00 ","$2,470.00 ",$691.60 ,"$2,260.05 ","$1,729.00 ","$2,067.39 ","$2,260.05 ","$2,260.05 ","$2,260.05 ",$910.20 ,"$1,482.00 ",$741.00 ,"$2,223.00 ","$1,852.50 ","$1,976.00 ","$2,050.10 "
Hoopeston Regional Hlth Center,9471551,MRI CHEST W/CONT,,71551,610,"$2,940.00 ","$2,940.00 ",$823.20 ,"$2,690.10 ","$2,058.00 ","$2,460.78 ","$2,690.10 ","$2,690.10 ","$2,690.10 ","$1,083.39 ","$1,764.00 ",$882.00 ,"$2,646.00 ","$2,205.00 ","$2,352.00 ","$2,440.20 "
Hoopeston Regional Hlth Center,9471552,MRI CHEST W/WO CONTRAST,,71552,610,"$5,090.00 ","$5,090.00 ","$1,425.20 ","$4,657.35 ","$3,563.00 ","$4,260.33 ","$4,657.35 ","$4,657.35 ","$4,657.35 ","$1,875.67 ","$3,054.00 ","$1,527.00 ","$4,581.00 ","$3,817.50 ","$4,072.00 ","$4,224.70 "
Hoopeston Regional Hlth Center,9472196,MRI PELVIS W/CONT,,72196,610,"$2,940.00 ","$2,940.00 ",$823.20 ,"$2,690.10 ","$2,058.00 ","$2,460.78 ","$2,690.10 ","$2,690.10 ","$2,690.10 ","$1,083.39 ","$1,764.00 ",$882.00 ,"$2,646.00 ","$2,205.00 ","$2,352.00 ","$2,440.20 "
Hoopeston Regional Hlth Center,9472197,MRI PELVIS W/WO CONT,,72197,610,"$5,300.00 ","$5,300.00 ","$1,484.00 ","$4,849.50 ","$3,710.00 ","$4,436.10 ","$4,849.50 ","$4,849.50 ","$4,849.50 ","$1,953.05 ","$3,180.00 ","$1,590.00 ","$4,770.00 ","$3,975.00 ","$4,240.00 ","$4,399.00 "
Hoopeston Regional Hlth Center,9473218,MRI UP EXT WO CONTRAST,,73218,610,"$3,140.00 ","$3,140.00 ",$879.20 ,"$2,873.10 ","$2,198.00 ","$2,628.18 ","$2,873.10 ","$2,873.10 ","$2,873.10 ","$1,157.09 ","$1,884.00 ",$942.00 ,"$2,826.00 ","$2,355.00 ","$2,512.00 ","$2,606.20 "
Hoopeston Regional Hlth Center,9473718,MRI LWR EXT WO CONTRAST,,73718,610,"$3,170.00 ","$3,170.00 ",$887.60 ,"$2,900.55 ","$2,219.00 ","$2,653.29 ","$2,900.55 ","$2,900.55 ","$2,900.55 ","$1,168.15 ","$1,902.00 ",$951.00 ,"$2,853.00 ","$2,377.50 ","$2,536.00 ","$2,631.10 "
Hoopeston Regional Hlth Center,9473720,MRI LOWER EXT NOT JOINT W/WO,,73720,610,"$2,520.00 ","$2,520.00 ",$705.60 ,"$2,305.80 ","$1,764.00 ","$2,109.24 ","$2,305.80 ","$2,305.80 ","$2,305.80 ",$928.62 ,"$1,512.00 ",$756.00 ,"$2,268.00 ","$1,890.00 ","$2,016.00 ","$2,091.60 "
Hoopeston Regional Hlth Center,9473721,MRI LWR EXT JOINT W/O CONTRAST,,73721,610,"$6,380.00 ","$6,380.00 ","$1,786.40 ","$5,837.70 ","$4,466.00 ","$5,340.06 ","$5,837.70 ","$5,837.70 ","$5,837.70 ","$2,351.03 ","$3,828.00 ","$1,914.00 ","$5,742.00 ","$4,785.00 ","$5,104.00 ","$5,295.40 "
Hoopeston Regional Hlth Center,9474181,MRI ABD OR AAA WO CONTRAST,,74181,610,"$2,480.00 ","$2,480.00 ",$694.40 ,"$2,269.20 ","$1,736.00 ","$2,075.76 ","$2,269.20 ","$2,269.20 ","$2,269.20 ",$913.88 ,"$1,488.00 ",$744.00 ,"$2,232.00 ","$1,860.00 ","$1,984.00 ","$2,058.40 "
Hoopeston Regional Hlth Center,9474182,MRI ABD W/CONT,,74182,610,"$3,030.00 ","$3,030.00 ",$848.40 ,"$2,772.45 ","$2,121.00 ","$2,536.11 ","$2,772.45 ","$2,772.45 ","$2,772.45 ","$1,116.56 ","$1,818.00 ",$909.00 ,"$2,727.00 ","$2,272.50 ","$2,424.00 ","$2,514.90 "
Hoopeston Regional Hlth Center,9474183,MRI ABD W/WO CONTRAST,,74183,610,"$6,410.00 ","$6,410.00 ","$1,794.80 ","$5,865.15 ","$4,487.00 ","$5,365.17 ","$5,865.15 ","$5,865.15 ","$5,865.15 ","$2,362.09 ","$3,846.00 ","$1,923.00 ","$5,769.00 ","$4,807.50 ","$5,128.00 ","$5,320.30 "
Hoopeston Regional Hlth Center,9474185,MRI MRCP,,74185,610,"$2,880.00 ","$2,880.00 ",$806.40 ,"$2,635.20 ","$2,016.00 ","$2,410.56 ","$2,635.20 ","$2,635.20 ","$2,635.20 ","$1,061.28 ","$1,728.00 ",$864.00 ,"$2,592.00 ","$2,160.00 ","$2,304.00 ","$2,390.40 "
Hoopeston Regional Hlth Center,9475557,MRI CARDIAC MORPHOLOGY WO CONT,,75557,610,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,9477058,MRI BREAST UNILAT W AND/OR WO CNTRST,,77058,610,"$3,920.00 ","$3,920.00 ","$1,097.60 ","$3,586.80 ","$2,744.00 ","$3,281.04 ","$3,586.80 ","$3,586.80 ","$3,586.80 ","$1,444.52 ","$2,352.00 ","$1,176.00 ","$3,528.00 ","$2,940.00 ","$3,136.00 ","$3,253.60 "
Hoopeston Regional Hlth Center,9477059,MRI BREAST BILAT W AND/OR WO CONTRAST,,77059,610,"$5,300.00 ","$5,300.00 ","$1,484.00 ","$4,849.50 ","$3,710.00 ","$4,436.10 ","$4,849.50 ","$4,849.50 ","$4,849.50 ","$1,953.05 ","$3,180.00 ","$1,590.00 ","$4,770.00 ","$3,975.00 ","$4,240.00 ","$4,399.00 "
Hoopeston Regional Hlth Center,9477084,MRI BONE MARROW BLOOD SUPPLY,,77084,610,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,9470543,MRI ORBIT/FACE/NECK W/WO CNTRST,,70543,610,"$5,280.00 ","$5,280.00 ","$1,478.40 ","$4,831.20 ","$3,696.00 ","$4,419.36 ","$4,831.20 ","$4,831.20 ","$4,831.20 ","$1,945.68 ","$3,168.00 ","$1,584.00 ","$4,752.00 ","$3,960.00 ","$4,224.00 ","$4,382.40 "
Hoopeston Regional Hlth Center,9472195,MRI PELVIS/SACRUM W/WO CONTRAST,,72195,610,"$2,620.00 ","$2,620.00 ",$733.60 ,"$2,397.30 ","$1,834.00 ","$2,192.94 ","$2,397.30 ","$2,397.30 ","$2,397.30 ",$965.47 ,"$1,572.00 ",$786.00 ,"$2,358.00 ","$1,965.00 ","$2,096.00 ","$2,174.60 "
Hoopeston Regional Hlth Center,9473221,MRI UP EXT JNT WO CONTRAST,,73221,610,"$2,910.00 ","$2,910.00 ",$814.80 ,"$2,662.65 ","$2,037.00 ","$2,435.67 ","$2,662.65 ","$2,662.65 ","$2,662.65 ","$1,072.34 ","$1,746.00 ",$873.00 ,"$2,619.00 ","$2,182.50 ","$2,328.00 ","$2,415.30 "
Hoopeston Regional Hlth Center,9473722,MRI LWR EXT JOINT W/ONTRAST,,73722,610,"$6,700.00 ","$6,700.00 ","$1,876.00 ","$6,130.50 ","$4,690.00 ","$5,607.90 ","$6,130.50 ","$6,130.50 ","$6,130.50 ","$2,468.95 ","$4,020.00 ","$2,010.00 ","$6,030.00 ","$5,025.00 ","$5,360.00 ","$5,561.00 "
Hoopeston Regional Hlth Center,9473723,MRI LWR EXT JOINT W & W/O CONTRAST,,73723,610,"$7,830.00 ","$7,830.00 ","$2,192.40 ","$7,164.45 ","$5,481.00 ","$6,553.71 ","$7,164.45 ","$7,164.45 ","$7,164.45 ","$2,885.36 ","$4,698.00 ","$2,349.00 ","$7,047.00 ","$5,872.50 ","$6,264.00 ","$6,498.90 "
Hoopeston Regional Hlth Center,9474712,FETAL MRI W/PLACNTL MATRNL PLVC IMG SING/1RST GES,,74712,610,"$4,730.00 ","$4,730.00 ","$1,324.40 ","$4,327.95 ","$3,311.00 ","$3,959.01 ","$4,327.95 ","$4,327.95 ","$4,327.95 ","$1,743.01 ","$2,838.00 ","$1,419.00 ","$4,257.00 ","$3,547.50 ","$3,784.00 ","$3,925.90 "
Hoopeston Regional Hlth Center,9474713,FETAL MRI W/PLACNTL MATRNL PLVC IMG EA ADDL GES,,74713,610,"$2,050.00 ","$2,050.00 ",$574.00 ,"$1,875.75 ","$1,435.00 ","$1,715.85 ","$1,875.75 ","$1,875.75 ","$1,875.75 ",$755.43 ,"$1,230.00 ",$615.00 ,"$1,845.00 ","$1,537.50 ","$1,640.00 ","$1,701.50 "
Hoopeston Regional Hlth Center,9473220,MRI UP EXT WO & W/CONTRAST,,73220,610,"$3,320.00 ","$3,320.00 ",$929.60 ,"$3,037.80 ","$2,324.00 ","$2,778.84 ","$3,037.80 ","$3,037.80 ","$3,037.80 ","$1,223.42 ","$1,992.00 ",$996.00 ,"$2,988.00 ","$2,490.00 ","$2,656.00 ","$2,755.60 "
Hoopeston Regional Hlth Center,9473719,MRI LOWER EXTREMITY W/CONTRAST,,73719,610,"$3,320.00 ","$3,320.00 ",$929.60 ,"$3,037.80 ","$2,324.00 ","$2,778.84 ","$3,037.80 ","$3,037.80 ","$3,037.80 ","$1,223.42 ","$1,992.00 ",$996.00 ,"$2,988.00 ","$2,490.00 ","$2,656.00 ","$2,755.60 "
Hoopeston Regional Hlth Center,9473219,MRI UPPER EXTREMITY W/CNTRST,,73219,610,"$3,340.00 ","$3,340.00 ",$935.20 ,"$3,056.10 ","$2,338.00 ","$2,795.58 ","$3,056.10 ","$3,056.10 ","$3,056.10 ","$1,230.79 ","$2,004.00 ","$1,002.00 ","$3,006.00 ","$2,505.00 ","$2,672.00 ","$2,772.20 "
Hoopeston Regional Hlth Center,9473223,MRI UPPR EXT JOINT W & W/O CONTRAST,,73223,610,"$5,930.00 ","$5,930.00 ","$1,660.40 ","$5,425.95 ","$4,151.00 ","$4,963.41 ","$5,425.95 ","$5,425.95 ","$5,425.95 ","$2,185.21 ","$3,558.00 ","$1,779.00 ","$5,337.00 ","$4,447.50 ","$4,744.00 ","$4,921.90 "
Hoopeston Regional Hlth Center,9408937,Cad breast mri,,C8937,610,"$2,030.00 ","$2,030.00 ",$568.40 ,"$1,857.45 ","$1,421.00 ","$1,699.11 ","$1,857.45 ","$1,857.45 ","$1,857.45 ",$748.06 ,"$1,218.00 ",$609.00 ,"$1,827.00 ","$1,522.50 ","$1,624.00 ","$1,684.90 "
Hoopeston Regional Hlth Center,9476391,MAGNETIC RESONANCE ELASTOGRAPHY,,76391,610,"$4,650.00 ","$4,650.00 ","$1,302.00 ","$4,254.75 ","$3,255.00 ","$3,892.05 ","$4,254.75 ","$4,254.75 ","$4,254.75 ","$1,713.53 ","$2,790.00 ","$1,395.00 ","$4,185.00 ","$3,487.50 ","$3,720.00 ","$3,859.50 "
Hoopeston Regional Hlth Center,9477046,MRI BREAST WITHOUT CONTRAST MATERIAL UNILATERAL,,77046,610,"$1,150.00 ","$1,150.00 ",$322.00 ,"$1,052.25 ",$805.00 ,$962.55 ,"$1,052.25 ","$1,052.25 ","$1,052.25 ",$423.78 ,$690.00 ,$345.00 ,"$1,035.00 ",$862.50 ,$920.00 ,$954.50
Hoopeston Regional Hlth Center,9477047,MRI BREAST WITHOUT CONTRAST MATERIAL BILATERAL,,77047,610,"$1,430.00 ","$1,430.00 ",$400.40 ,"$1,308.45 ","$1,001.00 ","$1,196.91 ","$1,308.45 ","$1,308.45 ","$1,308.45 ",$526.96 ,$858.00 ,$429.00 ,"$1,287.00 ","$1,072.50 ","$1,144.00 ","$1,186.90 "
Hoopeston Regional Hlth Center,9477048,MRI BREAST W/OUT&WITH CONTRAST W/CAD UNILATERAL,,C8905,610,"$1,830.00 ","$1,830.00 ",$512.40 ,"$1,674.45 ","$1,281.00 ","$1,531.71 ","$1,674.45 ","$1,674.45 ","$1,674.45 ",$674.36 ,"$1,098.00 ",$549.00 ,"$1,647.00 ","$1,372.50 ","$1,464.00 ","$1,518.90 "
Hoopeston Regional Hlth Center,9477049,MRI BREAST WITHOUT&WITH CONTRAST W/CAD BILATERAL,,C8908,610,"$2,240.00 ","$2,240.00 ",$627.20 ,"$2,049.60 ","$1,568.00 ","$1,874.88 ","$2,049.60 ","$2,049.60 ","$2,049.60 ",$825.44 ,"$1,344.00 ",$672.00 ,"$2,016.00 ","$1,680.00 ","$1,792.00 ","$1,859.20 "
Hoopeston Regional Hlth Center,9408906,MRI BREAST W/CONTRAST,,C8906,610,"$2,100.00 ","$2,100.00 ",$588.00 ,"$1,921.50 ","$1,470.00 ","$1,757.70 ","$1,921.50 ","$1,921.50 ","$1,921.50 ",$773.85 ,"$1,260.00 ",$630.00 ,"$1,890.00 ","$1,575.00 ","$1,680.00 ","$1,743.00 "
Hoopeston Regional Hlth Center,9408903,"MRI W/CONT, BREAST, UNI",,C8903,610,"$1,120.00 ","$1,120.00 ",$313.60 ,"$1,024.80 ",$784.00 ,$937.44 ,"$1,024.80 ","$1,024.80 ","$1,024.80 ",$412.72 ,$672.00 ,$336.00 ,"$1,008.00 ",$840.00 ,$896.00 ,$929.60
Hoopeston Regional Hlth Center,9470551,MRI BRAIN WO CONT,,70551,611,"$3,850.00 ","$3,850.00 ","$1,078.00 ","$3,522.75 ","$2,695.00 ","$3,222.45 ","$3,522.75 ","$3,522.75 ","$3,522.75 ","$1,418.73 ","$2,310.00 ","$1,155.00 ","$3,465.00 ","$2,887.50 ","$3,080.00 ","$3,195.50 "
Hoopeston Regional Hlth Center,9470552,MRI BRAIN W/CONT,,70552,611,"$2,840.00 ","$2,840.00 ",$795.20 ,"$2,598.60 ","$1,988.00 ","$2,377.08 ","$2,598.60 ","$2,598.60 ","$2,598.60 ","$1,046.54 ","$1,704.00 ",$852.00 ,"$2,556.00 ","$2,130.00 ","$2,272.00 ","$2,357.20 "
Hoopeston Regional Hlth Center,9470553,MRI BRAIN W/WO CONT,,70553,611,"$6,540.00 ","$6,540.00 ","$1,831.20 ","$5,984.10 ","$4,578.00 ","$5,473.98 ","$5,984.10 ","$5,984.10 ","$5,984.10 ","$2,409.99 ","$3,924.00 ","$1,962.00 ","$5,886.00 ","$4,905.00 ","$5,232.00 ","$5,428.20 "
Hoopeston Regional Hlth Center,9472141,MRI C-SPINE WO CONT,,72141,612,"$3,390.00 ","$3,390.00 ",$949.20 ,"$3,101.85 ","$2,373.00 ","$2,837.43 ","$3,101.85 ","$3,101.85 ","$3,101.85 ","$1,249.22 ","$2,034.00 ","$1,017.00 ","$3,051.00 ","$2,542.50 ","$2,712.00 ","$2,813.70 "
Hoopeston Regional Hlth Center,9472142,MRI C-SPINE W/CONT,,72142,612,"$2,990.00 ","$2,990.00 ",$837.20 ,"$2,735.85 ","$2,093.00 ","$2,502.63 ","$2,735.85 ","$2,735.85 ","$2,735.85 ","$1,101.82 ","$1,794.00 ",$897.00 ,"$2,691.00 ","$2,242.50 ","$2,392.00 ","$2,481.70 "
Hoopeston Regional Hlth Center,9472146,MRI T-SPINE WO CONT,,72146,612,"$3,340.00 ","$3,340.00 ",$935.20 ,"$3,056.10 ","$2,338.00 ","$2,795.58 ","$3,056.10 ","$3,056.10 ","$3,056.10 ","$1,230.79 ","$2,004.00 ","$1,002.00 ","$3,006.00 ","$2,505.00 ","$2,672.00 ","$2,772.20 "
Hoopeston Regional Hlth Center,9472147,MRI T-SPINE W/CONT,,72147,612,"$3,130.00 ","$3,130.00 ",$876.40 ,"$2,863.95 ","$2,191.00 ","$2,619.81 ","$2,863.95 ","$2,863.95 ","$2,863.95 ","$1,153.41 ","$1,878.00 ",$939.00 ,"$2,817.00 ","$2,347.50 ","$2,504.00 ","$2,597.90 "
Hoopeston Regional Hlth Center,9472148,MRI L-SPINE WO CONT,,72148,612,"$3,950.00 ","$3,950.00 ","$1,106.00 ","$3,614.25 ","$2,765.00 ","$3,306.15 ","$3,614.25 ","$3,614.25 ","$3,614.25 ","$1,455.58 ","$2,370.00 ","$1,185.00 ","$3,555.00 ","$2,962.50 ","$3,160.00 ","$3,278.50 "
Hoopeston Regional Hlth Center,9472149,MRI L-SPINE W/CONT,,72149,612,"$2,840.00 ","$2,840.00 ",$795.20 ,"$2,598.60 ","$1,988.00 ","$2,377.08 ","$2,598.60 ","$2,598.60 ","$2,598.60 ","$1,046.54 ","$1,704.00 ",$852.00 ,"$2,556.00 ","$2,130.00 ","$2,272.00 ","$2,357.20 "
Hoopeston Regional Hlth Center,9472156,MRI C-SPINE W/WO CONT,,72156,612,"$6,540.00 ","$6,540.00 ","$1,831.20 ","$5,984.10 ","$4,578.00 ","$5,473.98 ","$5,984.10 ","$5,984.10 ","$5,984.10 ","$2,409.99 ","$3,924.00 ","$1,962.00 ","$5,886.00 ","$4,905.00 ","$5,232.00 ","$5,428.20 "
Hoopeston Regional Hlth Center,9472157,MRI T-SPINE W/WO CONT,,72157,612,"$5,410.00 ","$5,410.00 ","$1,514.80 ","$4,950.15 ","$3,787.00 ","$4,528.17 ","$4,950.15 ","$4,950.15 ","$4,950.15 ","$1,993.59 ","$3,246.00 ","$1,623.00 ","$4,869.00 ","$4,057.50 ","$4,328.00 ","$4,490.30 "
Hoopeston Regional Hlth Center,9472158,MRI L-SPINE W/WO CONT,,72158,612,"$6,540.00 ","$6,540.00 ","$1,831.20 ","$5,984.10 ","$4,578.00 ","$5,473.98 ","$5,984.10 ","$5,984.10 ","$5,984.10 ","$2,409.99 ","$3,924.00 ","$1,962.00 ","$5,886.00 ","$4,905.00 ","$5,232.00 ","$5,428.20 "
Hoopeston Regional Hlth Center,9470544,MRA HEAD W/O CONT,,70544,615,"$2,470.00 ","$2,470.00 ",$691.60 ,"$2,260.05 ","$1,729.00 ","$2,067.39 ","$2,260.05 ","$2,260.05 ","$2,260.05 ",$910.20 ,"$1,482.00 ",$741.00 ,"$2,223.00 ","$1,852.50 ","$1,976.00 ","$2,050.10 "
Hoopeston Regional Hlth Center,9470545,MRA HEAD W/CONT,,70545,615,"$2,940.00 ","$2,940.00 ",$823.20 ,"$2,690.10 ","$2,058.00 ","$2,460.78 ","$2,690.10 ","$2,690.10 ","$2,690.10 ","$1,083.39 ","$1,764.00 ",$882.00 ,"$2,646.00 ","$2,205.00 ","$2,352.00 ","$2,440.20 "
Hoopeston Regional Hlth Center,9470546,MRA HEAD W/WO CONT,,70546,615,"$4,820.00 ","$4,820.00 ","$1,349.60 ","$4,410.30 ","$3,374.00 ","$4,034.34 ","$4,410.30 ","$4,410.30 ","$4,410.30 ","$1,776.17 ","$2,892.00 ","$1,446.00 ","$4,338.00 ","$3,615.00 ","$3,856.00 ","$4,000.60 "
Hoopeston Regional Hlth Center,9470547,MRA NECK WO CONT,,70547,615,"$2,560.00 ","$2,560.00 ",$716.80 ,"$2,342.40 ","$1,792.00 ","$2,142.72 ","$2,342.40 ","$2,342.40 ","$2,342.40 ",$943.36 ,"$1,536.00 ",$768.00 ,"$2,304.00 ","$1,920.00 ","$2,048.00 ","$2,124.80 "
Hoopeston Regional Hlth Center,9470548,MRA NECK W/CONT,,70548,615,"$2,700.00 ","$2,700.00 ",$756.00 ,"$2,470.50 ","$1,890.00 ","$2,259.90 ","$2,470.50 ","$2,470.50 ","$2,470.50 ",$994.95 ,"$1,620.00 ",$810.00 ,"$2,430.00 ","$2,025.00 ","$2,160.00 ","$2,241.00 "
Hoopeston Regional Hlth Center,9470549,MRA NECK W/WO CONT,,70549,615,"$5,540.00 ","$5,540.00 ","$1,551.20 ","$5,069.10 ","$3,878.00 ","$4,636.98 ","$5,069.10 ","$5,069.10 ","$5,069.10 ","$2,041.49 ","$3,324.00 ","$1,662.00 ","$4,986.00 ","$4,155.00 ","$4,432.00 ","$4,598.20 "
Hoopeston Regional Hlth Center,9473725,MRA BILAT LOW EXT,,73725,616,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,9471555,MRA CHEST W OR WO CNTRST,,71555,618,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,9473225,MRA ARM W OR WO CNTRST,,73225,618,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,9472198,MRA PELVIS W OR WO CNTRST,,72198,618,"$2,500.00 ","$2,500.00 ",$700.00 ,"$2,287.50 ","$1,750.00 ","$2,092.50 ","$2,287.50 ","$2,287.50 ","$2,287.50 ",$921.25 ,"$1,500.00 ",$750.00 ,"$2,250.00 ","$1,875.00 ","$2,000.00 ","$2,075.00 "
Hoopeston Regional Hlth Center,8980635,"epoetin alfa-epbx 10,000 unit/mL injection solution",69130810,,635,$585.40 ,$585.40 ,$163.91 ,$535.64 ,$409.78 ,$489.98 ,$535.64 ,$535.64 ,$535.64 ,$215.72 ,$351.24 ,$175.62 ,$526.86 ,$439.05 ,$468.32 ,$485.88
Hoopeston Regional Hlth Center,8980635,"epoetin alfa-epbx 40,000 unit/mL injection solution",69130904,,635,"$1,975.18 ","$1,975.18 ",$553.05 ,"$1,807.29 ","$1,382.63 ","$1,653.23 ","$1,807.29 ","$1,807.29 ","$1,807.29 ",$727.85 ,"$1,185.11 ",$592.55 ,"$1,777.66 ","$1,481.39 ","$1,580.14 ","$1,639.40 "
Hoopeston Regional Hlth Center,8980635,"epoetin alfa-epbx 20,000 unit/mL injection solution",69131110,,635,"$1,048.66 ","$1,048.66 ",$293.62 ,$959.52 ,$734.06 ,$877.73 ,$959.52 ,$959.52 ,$959.52 ,$386.43 ,$629.20 ,$314.60 ,$943.79 ,$786.50 ,$838.93 ,$870.39
Hoopeston Regional Hlth Center,9378999,I-131 SODIUM IODIDE CAP PR MCI,,A9517,636,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,9386998,RHO D IMMUNE GLOBULIN - 50 MCG,,J2788,636,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,9386997,RHIG (300 MICROGRAMS),,J2790,636,"$1,450.00 ","$1,450.00 ",$406.00 ,"$1,326.75 ","$1,015.00 ","$1,213.65 ","$1,326.75 ","$1,326.75 ","$1,326.75 ",$534.33 ,$870.00 ,$435.00 ,"$1,305.00 ","$1,087.50 ","$1,160.00 ","$1,203.50 "
Hoopeston Regional Hlth Center,9290658,HRHC FLU CLINIC VACCINE,,90658,636,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,8980010,"MFN DRUG ADD-ON, PER DOSE",,M1145,636,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,8980636,insulin lispro (U-100) 100 unit/mL subcutaneous solution,2751001,J1815,636,$45.01 ,$45.01 ,$12.60 ,$41.18 ,$31.51 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.59 ,$27.01 ,$13.50 ,$40.51 ,$33.76 ,$36.01 ,$37.36
Hoopeston Regional Hlth Center,8980636,insulin lispro protamine-lispro 100 unit/mL (75-25) subcutaneous susp,2751101,J1815,636,$45.29 ,$45.29 ,$12.68 ,$41.44 ,$31.70 ,$37.91 ,$41.44 ,$41.44 ,$41.44 ,$16.69 ,$27.17 ,$13.59 ,$40.76 ,$33.97 ,$36.23 ,$37.59
Hoopeston Regional Hlth Center,8980636,"insulin regular human U-500""concentrate"" 500 unit/mL subcutaneous soln",2850101,J1815,636,"$8,336.27 ","$8,336.27 ","$2,334.16 ","$7,627.69 ","$5,835.39 ","$6,977.46 ","$7,627.69 ","$7,627.69 ","$7,627.69 ","$3,071.92 ","$5,001.76 ","$2,500.88 ","$7,502.64 ","$6,252.20 ","$6,669.02 ","$6,919.10 "
Hoopeston Regional Hlth Center,8980636,insulin NPH isophane U-100 human 100 unit/mL (3 mL) subcutaneous pen,2880559,J1815,636,$548.07 ,$548.07 ,$153.46 ,$501.48 ,$383.65 ,$458.73 ,$501.48 ,$501.48 ,$501.48 ,$201.96 ,$328.84 ,$164.42 ,$493.26 ,$411.05 ,$438.46 ,$454.90
Hoopeston Regional Hlth Center,8980636,"insulin regular human U-500 ""concentrate"" 500 unit/mL(3 mL) subcut pen",2882401,J1815,636,"$1,626.43 ","$1,626.43 ",$455.40 ,"$1,488.18 ","$1,138.50 ","$1,361.32 ","$1,488.18 ","$1,488.18 ","$1,488.18 ",$599.34 ,$975.86 ,$487.93 ,"$1,463.79 ","$1,219.82 ","$1,301.14 ","$1,349.94 "
Hoopeston Regional Hlth Center,8980636,"insulin regular human U-500 ""concentrate"" 500 unit/mL(3 mL) subcut pen",2882427,J1815,636,"$1,626.43 ","$1,626.43 ",$455.40 ,"$1,488.18 ","$1,138.50 ","$1,361.32 ","$1,488.18 ","$1,488.18 ","$1,488.18 ",$599.34 ,$975.86 ,$487.93 ,"$1,463.79 ","$1,219.82 ","$1,301.14 ","$1,349.94 "
Hoopeston Regional Hlth Center,8980636,triamcinolone acetonide 40 mg/mL suspension for injection,3029305,J3301,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,triamcinolone acetonide 10 mg/mL suspension for injection,3049420,J3301,636,$87.85 ,$87.85 ,$24.60 ,$80.38 ,$61.50 ,$73.53 ,$80.38 ,$80.38 ,$80.38 ,$32.37 ,$52.71 ,$26.36 ,$79.07 ,$65.89 ,$70.28 ,$72.92
Hoopeston Regional Hlth Center,8980636,abatacept (with maltose) 250 mg intravenous solution,3218710,J0129,636,"$13,211.61 ","$13,211.61 ","$3,699.25 ","$12,088.62 ","$9,248.13 ","$11,058.12 ","$12,088.62 ","$12,088.62 ","$12,088.62 ","$4,868.48 ","$7,926.97 ","$3,963.48 ","$11,890.45 ","$9,908.71 ","$10,569.29 ","$10,965.64 "
Hoopeston Regional Hlth Center,8980636,inFLIXimab-abda 100 mg intravenous solution,6430502,,636,"$4,277.04 ","$4,277.04 ","$1,197.57 ","$3,913.49 ","$2,993.93 ","$3,579.88 ","$3,913.49 ","$3,913.49 ","$3,913.49 ","$1,576.09 ","$2,566.22 ","$1,283.11 ","$3,849.34 ","$3,207.78 ","$3,421.63 ","$3,549.94 "
Hoopeston Regional Hlth Center,8980636,"measles,mumps,rubella vaccine live(PF)1,000-12,500TCID50/0.5 mL subcut",6468100,90707,636,$193.42 ,$193.42 ,$54.16 ,$176.98 ,$135.39 ,$161.89 ,$176.98 ,$176.98 ,$176.98 ,$71.28 ,$116.05 ,$58.03 ,$174.08 ,$145.07 ,$154.74 ,$160.54
Hoopeston Regional Hlth Center,8980636,"varicella virus vaccine live (PF) 1,350 unit/0.5 mL subcutaneous susp",6482700,90716,636,$335.61 ,$335.61 ,$93.97 ,$307.08 ,$234.93 ,$280.91 ,$307.08 ,$307.08 ,$307.08 ,$123.67 ,$201.37 ,$100.68 ,$302.05 ,$251.71 ,$268.49 ,$278.56
Hoopeston Regional Hlth Center,8980636,"varicella virus vaccine live (PF) 1,350 unit/0.5 mL subcutaneous susp",6482701,90716,636,$335.61 ,$335.61 ,$93.97 ,$307.08 ,$234.93 ,$280.91 ,$307.08 ,$307.08 ,$307.08 ,$123.67 ,$201.37 ,$100.68 ,$302.05 ,$251.71 ,$268.49 ,$278.56
Hoopeston Regional Hlth Center,8980636,haemoph b polysac conj-mening (PF) 7.5 mcg/0.5 mL intramuscular soln,6489700,90647,636,$62.12 ,$62.12 ,$17.39 ,$56.84 ,$43.48 ,$51.99 ,$56.84 ,$56.84 ,$56.84 ,$22.89 ,$37.27 ,$18.64 ,$55.91 ,$46.59 ,$49.70 ,$51.56
Hoopeston Regional Hlth Center,8980636,pneumococcal 23 polyvalent vaccine 25 mcg/0.5 mL injection solution,6494300,90732,636,$260.48 ,$260.48 ,$72.93 ,$238.34 ,$182.34 ,$218.02 ,$238.34 ,$238.34 ,$238.34 ,$95.99 ,$156.29 ,$78.14 ,$234.43 ,$195.36 ,$208.38 ,$216.20
Hoopeston Regional Hlth Center,8980636,"zoster vaccine live (PF) 19,400 unit/0.65 mL subcutaneous suspension",6496301,90736,636,$496.39 ,$496.39 ,$138.99 ,$454.20 ,$347.47 ,$415.48 ,$454.20 ,$454.20 ,$454.20 ,$182.92 ,$297.83 ,$148.92 ,$446.75 ,$372.29 ,$397.11 ,$412.00
Hoopeston Regional Hlth Center,8980636,"zoster vaccine live (PF) 19,400 unit/0.65 mL subcutaneous suspension",6496341,90736,636,$473.14 ,$473.14 ,$132.48 ,$432.92 ,$331.20 ,$396.02 ,$432.92 ,$432.92 ,$432.92 ,$174.35 ,$283.88 ,$141.94 ,$425.83 ,$354.86 ,$378.51 ,$392.71
Hoopeston Regional Hlth Center,8980636,pantoprazole 40 mg intravenous solution,8092351,C9113,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,pantoprazole 40 mg intravenous solution,8092355,C9113,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,methylPREDNISolone sod succ (PF) 500 mg/4 mL intravenous solution,9000302,J2930,636,$266.60 ,$266.60 ,$74.65 ,$243.94 ,$186.62 ,$223.14 ,$243.94 ,$243.94 ,$243.94 ,$98.24 ,$159.96 ,$79.98 ,$239.94 ,$199.95 ,$213.28 ,$221.28
Hoopeston Regional Hlth Center,8980636,hydrocortisone sod succinate (PF) 100 mg/2 mL solution for injection,9001103,J1720,636,$111.19 ,$111.19 ,$31.13 ,$101.74 ,$77.83 ,$93.07 ,$101.74 ,$101.74 ,$101.74 ,$40.97 ,$66.71 ,$33.36 ,$100.07 ,$83.39 ,$88.95 ,$92.29
Hoopeston Regional Hlth Center,8980636,hydrocortisone sod succinate (PF) 250 mg/2 mL solution for injection,9001305,J1720,636,$164.98 ,$164.98 ,$46.19 ,$150.96 ,$115.49 ,$138.09 ,$150.96 ,$150.96 ,$150.96 ,$60.80 ,$98.99 ,$49.49 ,$148.48 ,$123.74 ,$131.98 ,$136.93
Hoopeston Regional Hlth Center,8980636,"methylPREDNISolone sod succ (PF) 1,000 mg/8 mL intravenous solution",9001820,J2930,636,$370.85 ,$370.85 ,$103.84 ,$339.33 ,$259.60 ,$310.40 ,$339.33 ,$339.33 ,$339.33 ,$136.66 ,$222.51 ,$111.26 ,$333.77 ,$278.14 ,$296.68 ,$307.81
Hoopeston Regional Hlth Center,8980636,methylPREDNISolone sod succ (PF) 40 mg/mL solution for injection,9003928,J2920,636,$45.62 ,$45.62 ,$12.77 ,$41.74 ,$31.93 ,$38.18 ,$41.74 ,$41.74 ,$41.74 ,$16.81 ,$27.37 ,$13.69 ,$41.06 ,$34.22 ,$36.50 ,$37.86
Hoopeston Regional Hlth Center,8980636,methylPREDNISolone sod succ (PF) 125 mg/2 mL solution for injection,9004722,J2930,636,$71.40 ,$71.40 ,$19.99 ,$65.33 ,$49.98 ,$59.76 ,$65.33 ,$65.33 ,$65.33 ,$26.31 ,$42.84 ,$21.42 ,$64.26 ,$53.55 ,$57.12 ,$59.26
Hoopeston Regional Hlth Center,8980636,estradiol cypionate 5 mg/mL intramuscular oil,9027101,J1000,636,$811.91 ,$811.91 ,$227.33 ,$742.90 ,$568.34 ,$679.57 ,$742.90 ,$742.90 ,$742.90 ,$299.19 ,$487.15 ,$243.57 ,$730.72 ,$608.93 ,$649.53 ,$673.89
Hoopeston Regional Hlth Center,8980636,methylPREDNISolone acetate 40 mg/mL suspension for injection,9028002,J1030,636,$67.75 ,$67.75 ,$18.97 ,$61.99 ,$47.43 ,$56.71 ,$61.99 ,$61.99 ,$61.99 ,$24.97 ,$40.65 ,$20.33 ,$60.98 ,$50.81 ,$54.20 ,$56.23
Hoopeston Regional Hlth Center,8980636,methylPREDNISolone acetate 40 mg/mL suspension for injection,9307303,J1030,636,$77.61 ,$77.61 ,$21.73 ,$71.01 ,$54.33 ,$64.96 ,$71.01 ,$71.01 ,$71.01 ,$28.60 ,$46.57 ,$23.28 ,$69.85 ,$58.21 ,$62.09 ,$64.42
Hoopeston Regional Hlth Center,8980636,ibutilide fumarate 0.1 mg/mL intravenous solution,9379401,J1742,636,"$2,605.82 ","$2,605.82 ",$729.63 ,"$2,384.33 ","$1,824.07 ","$2,181.07 ","$2,384.33 ","$2,384.33 ","$2,384.33 ",$960.24 ,"$1,563.49 ",$781.75 ,"$2,345.24 ","$1,954.37 ","$2,084.66 ","$2,162.83 "
Hoopeston Regional Hlth Center,8980636,irinotecan 100 mg/5 mL intravenous solution,9752903,J9206,636,$314.44 ,$314.44 ,$88.04 ,$287.71 ,$220.11 ,$263.19 ,$287.71 ,$287.71 ,$287.71 ,$115.87 ,$188.66 ,$94.33 ,$283.00 ,$235.83 ,$251.55 ,$260.99
Hoopeston Regional Hlth Center,8980636,onabotulinumtoxinA 100 unit solution for injection,23114501,J0585,636,"$2,734.54 ","$2,734.54 ",$765.67 ,"$2,502.10 ","$1,914.18 ","$2,288.81 ","$2,502.10 ","$2,502.10 ","$2,502.10 ","$1,007.68 ","$1,640.72 ",$820.36 ,"$2,461.09 ","$2,050.91 ","$2,187.63 ","$2,269.67 "
Hoopeston Regional Hlth Center,8980636,conjugated estrogens 25 mg solution for injection,46074905,J1410,636,"$1,496.45 ","$1,496.45 ",$419.01 ,"$1,369.25 ","$1,047.52 ","$1,252.53 ","$1,369.25 ","$1,369.25 ","$1,369.25 ",$551.44 ,$897.87 ,$448.94 ,"$1,346.81 ","$1,122.34 ","$1,197.16 ","$1,242.05 "
Hoopeston Regional Hlth Center,8980636,penicillin G potassium 5 million unit solution for injection,49052083,J2540,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,voriconazole 200 mg intravenous solution,49319028,J3465,636,$902.54 ,$902.54 ,$252.71 ,$825.82 ,$631.78 ,$755.43 ,$825.82 ,$825.82 ,$825.82 ,$332.59 ,$541.52 ,$270.76 ,$812.29 ,$676.91 ,$722.03 ,$749.11
Hoopeston Regional Hlth Center,8980636,predniSONE 5 mg/mL oral concentrate,54372144,,636,$37.25 ,$37.25 ,$10.43 ,$34.08 ,$26.08 ,$31.18 ,$34.08 ,$34.08 ,$34.08 ,$13.73 ,$22.35 ,$11.18 ,$33.53 ,$27.94 ,$29.80 ,$30.92
Hoopeston Regional Hlth Center,8980636,predniSONE 5 mg/5 mL oral solution,54372263,,636,$28.64 ,$28.64 ,$8.02 ,$26.21 ,$20.05 ,$23.97 ,$26.21 ,$26.21 ,$26.21 ,$10.55 ,$17.18 ,$8.59 ,$25.78 ,$21.48 ,$22.91 ,$23.77
Hoopeston Regional Hlth Center,8980636,dexAMETHasone 4 mg tablet,54418425,,636,$2.68 ,$2.68 ,$0.75 ,$2.45 ,$1.88 ,$2.24 ,$2.45 ,$2.45 ,$2.45 ,$0.99 ,$1.61 ,$0.80 ,$2.41 ,$2.01 ,$2.14 ,$2.22
Hoopeston Regional Hlth Center,8980636,mercaptopurine 50 mg tablet,54458111,J8499,636,$145.61 ,$145.61 ,$40.77 ,$133.23 ,$101.93 ,$121.88 ,$133.23 ,$133.23 ,$133.23 ,$53.66 ,$87.37 ,$43.68 ,$131.05 ,$109.21 ,$116.49 ,$120.86
Hoopeston Regional Hlth Center,8980636,predniSONE 5 mg tablet,54472825,,636,$3.38 ,$3.38 ,$0.95 ,$3.09 ,$2.37 ,$2.83 ,$3.09 ,$3.09 ,$3.09 ,$1.25 ,$2.03 ,$1.01 ,$3.04 ,$2.54 ,$2.70 ,$2.81
Hoopeston Regional Hlth Center,8980636,dexAMETHasone 1 mg tablet,54817425,J8540,636,$2.76 ,$2.76 ,$0.77 ,$2.53 ,$1.93 ,$2.31 ,$2.53 ,$2.53 ,$2.53 ,$1.02 ,$1.66 ,$0.83 ,$2.48 ,$2.07 ,$2.21 ,$2.29
Hoopeston Regional Hlth Center,8980636,dexAMETHasone 2 mg tablet,54817625,J8540,636,$2.76 ,$2.76 ,$0.77 ,$2.53 ,$1.93 ,$2.31 ,$2.53 ,$2.53 ,$2.53 ,$1.02 ,$1.66 ,$0.83 ,$2.48 ,$2.07 ,$2.21 ,$2.29
Hoopeston Regional Hlth Center,8980636,dexAMETHasone 0.75 mg tablet,54818025,J8540,636,$2.74 ,$2.74 ,$0.77 ,$2.51 ,$1.92 ,$2.29 ,$2.51 ,$2.51 ,$2.51 ,$1.01 ,$1.64 ,$0.82 ,$2.47 ,$2.06 ,$2.19 ,$2.27
Hoopeston Regional Hlth Center,8980636,dexAMETHasone 1.5 mg tablet,54818125,J8540,636,$2.76 ,$2.76 ,$0.77 ,$2.53 ,$1.93 ,$2.31 ,$2.53 ,$2.53 ,$2.53 ,$1.02 ,$1.66 ,$0.83 ,$2.48 ,$2.07 ,$2.21 ,$2.29
Hoopeston Regional Hlth Center,8980636,methotrexate sodium 2.5 mg tablet,54855025,J8610,636,$145.61 ,$145.61 ,$40.77 ,$133.23 ,$101.93 ,$121.88 ,$133.23 ,$133.23 ,$133.23 ,$53.66 ,$87.37 ,$43.68 ,$131.05 ,$109.21 ,$116.49 ,$120.86
Hoopeston Regional Hlth Center,8980636,predniSONE 1 mg tablet,54873925,,636,$3.63 ,$3.63 ,$1.02 ,$3.32 ,$2.54 ,$3.04 ,$3.32 ,$3.32 ,$3.32 ,$1.34 ,$2.18 ,$1.09 ,$3.27 ,$2.72 ,$2.90 ,$3.01
Hoopeston Regional Hlth Center,8980636,inFLIXimab-dyyb 100 mg intravenous solution,69080901,,636,"$5,355.69 ","$5,355.69 ","$1,499.59 ","$4,900.46 ","$3,748.98 ","$4,482.71 ","$4,900.46 ","$4,900.46 ","$4,900.46 ","$1,973.57 ","$3,213.41 ","$1,606.71 ","$4,820.12 ","$4,016.77 ","$4,284.55 ","$4,445.22 "
Hoopeston Regional Hlth Center,8980636,SUNItinib 50 mg capsule,69098038,J8999,636,"$1,047.48 ","$1,047.48 ",$293.29 ,$958.44 ,$733.24 ,$876.74 ,$958.44 ,$958.44 ,$958.44 ,$386.00 ,$628.49 ,$314.24 ,$942.73 ,$785.61 ,$837.98 ,$869.41
Hoopeston Regional Hlth Center,8980636,leuprolide 22.5 mg (3 month) intramuscular syringe kit,74334603,J9217,636,"$18,600.60 ","$18,600.60 ","$5,208.17 ","$17,019.55 ","$13,020.42 ","$15,568.70 ","$17,019.55 ","$17,019.55 ","$17,019.55 ","$6,854.32 ","$11,160.36 ","$5,580.18 ","$16,740.54 ","$13,950.45 ","$14,880.48 ","$15,438.50 "
Hoopeston Regional Hlth Center,8980636,leuprolide 3.75 mg intramuscular syringe kit,74364103,J1950,636,"$6,351.55 ","$6,351.55 ","$1,778.43 ","$5,811.67 ","$4,446.09 ","$5,316.25 ","$5,811.67 ","$5,811.67 ","$5,811.67 ","$2,340.55 ","$3,810.93 ","$1,905.47 ","$5,716.40 ","$4,763.66 ","$5,081.24 ","$5,271.79 "
Hoopeston Regional Hlth Center,8980636,leuprolide 7.5 mg intramuscular syringe kit,74364203,J9217,636,"$7,545.43 ","$7,545.43 ","$2,112.72 ","$6,904.07 ","$5,281.80 ","$6,315.52 ","$6,904.07 ","$6,904.07 ","$6,904.07 ","$2,780.49 ","$4,527.26 ","$2,263.63 ","$6,790.89 ","$5,659.07 ","$6,036.34 ","$6,262.71 "
Hoopeston Regional Hlth Center,8980636,leuprolide 11.25 mg (3 month) intramuscular syringe kit,74366303,J1950,636,"$15,622.85 ","$15,622.85 ","$4,374.40 ","$14,294.91 ","$10,936.00 ","$13,076.33 ","$14,294.91 ","$14,294.91 ","$14,294.91 ","$5,757.02 ","$9,373.71 ","$4,686.86 ","$14,060.57 ","$11,717.14 ","$12,498.28 ","$12,966.97 "
Hoopeston Regional Hlth Center,8980636,leuprolide 30 mg (4 month) intramuscular syringe kit,74368303,J9217,636,"$24,772.56 ","$24,772.56 ","$6,936.32 ","$22,666.89 ","$17,340.79 ","$20,734.63 ","$22,666.89 ","$22,666.89 ","$22,666.89 ","$9,128.69 ","$14,863.54 ","$7,431.77 ","$22,295.30 ","$18,579.42 ","$19,818.05 ","$20,561.22 "
Hoopeston Regional Hlth Center,8980636,enoxaparin 100 mg/mL subcutaneous syringe,75062300,J1650,636,$469.84 ,$469.84 ,$131.56 ,$429.90 ,$328.89 ,$393.26 ,$429.90 ,$429.90 ,$429.90 ,$173.14 ,$281.90 ,$140.95 ,$422.86 ,$352.38 ,$375.87 ,$389.97
Hoopeston Regional Hlth Center,8980636,enoxaparin 150 mg/mL subcutaneous syringe,75291501,J1650,636,$643.88 ,$643.88 ,$180.29 ,$589.15 ,$450.72 ,$538.93 ,$589.15 ,$589.15 ,$589.15 ,$237.27 ,$386.33 ,$193.16 ,$579.49 ,$482.91 ,$515.10 ,$534.42
Hoopeston Regional Hlth Center,8980636,cycloSPORINE 100 mg/mL oral solution,78011022,J7502,636,$108.32 ,$108.32 ,$30.33 ,$99.11 ,$75.82 ,$90.66 ,$99.11 ,$99.11 ,$99.11 ,$39.92 ,$64.99 ,$32.50 ,$97.49 ,$81.24 ,$86.66 ,$89.91
Hoopeston Regional Hlth Center,8980636,cycloSPORINE 25 mg capsule,78024015,J7515,636,$23.97 ,$23.97 ,$6.71 ,$21.93 ,$16.78 ,$20.06 ,$21.93 ,$21.93 ,$21.93 ,$8.83 ,$14.38 ,$7.19 ,$21.57 ,$17.98 ,$19.18 ,$19.90
Hoopeston Regional Hlth Center,8980636,cycloSPORINE 100 mg capsule,78024115,J7502,636,$73.01 ,$73.01 ,$20.44 ,$66.80 ,$51.11 ,$61.11 ,$66.80 ,$66.80 ,$66.80 ,$26.90 ,$43.81 ,$21.90 ,$65.71 ,$54.76 ,$58.41 ,$60.60
Hoopeston Regional Hlth Center,8980636,cycloSPORINE modified 25 mg capsule,78024615,J7515,636,$14.93 ,$14.93 ,$4.18 ,$13.66 ,$10.45 ,$12.50 ,$13.66 ,$13.66 ,$13.66 ,$5.50 ,$8.96 ,$4.48 ,$13.44 ,$11.20 ,$11.94 ,$12.39
Hoopeston Regional Hlth Center,8980636,cycloSPORINE modified 100 mg/mL oral solution,78027422,J7502,636,"$3,433.81 ","$3,433.81 ",$961.47 ,"$3,141.94 ","$2,403.67 ","$2,874.10 ","$3,141.94 ","$3,141.94 ","$3,141.94 ","$1,265.36 ","$2,060.29 ","$1,030.14 ","$3,090.43 ","$2,575.36 ","$2,747.05 ","$2,850.06 "
Hoopeston Regional Hlth Center,8980636,imatinib 400 mg tablet,78043815,S0088,636,"$1,083.00 ","$1,083.00 ",$303.24 ,$990.95 ,$758.10 ,$906.47 ,$990.95 ,$990.95 ,$990.95 ,$399.09 ,$649.80 ,$324.90 ,$974.70 ,$812.25 ,$866.40 ,$898.89
Hoopeston Regional Hlth Center,8980636,"octreotide,microspheres ER 20 mg intramuscular susp, extended release",78081881,J2353,636,"$14,977.30 ","$14,977.30 ","$4,193.64 ","$13,704.23 ","$10,484.11 ","$12,536.00 ","$13,704.23 ","$13,704.23 ","$13,704.23 ","$5,519.14 ","$8,986.38 ","$4,493.19 ","$13,479.57 ","$11,232.98 ","$11,981.84 ","$12,431.16 "
Hoopeston Regional Hlth Center,8980636,"octreotide,microspheres ER 30 mg intramuscular susp, extended release",78082581,J2353,636,"$22,385.23 ","$22,385.23 ","$6,267.86 ","$20,482.49 ","$15,669.66 ","$18,736.44 ","$20,482.49 ","$20,482.49 ","$20,482.49 ","$8,248.96 ","$13,431.14 ","$6,715.57 ","$20,146.71 ","$16,788.92 ","$17,908.18 ","$18,579.74 "
Hoopeston Regional Hlth Center,8980636,interferon alfa-2b 10 million unit (1 mL) solution for injection,85435001,J9214,636,$767.47 ,$767.47 ,$214.89 ,$702.24 ,$537.23 ,$642.37 ,$702.24 ,$702.24 ,$702.24 ,$282.81 ,$460.48 ,$230.24 ,$690.72 ,$575.60 ,$613.98 ,$637.00
Hoopeston Regional Hlth Center,8980636,interferon alfa-2b 18 million unit (1 mL) solution for injection,85435101,J9214,636,"$2,445.34 ","$2,445.34 ",$684.70 ,"$2,237.49 ","$1,711.74 ","$2,046.75 ","$2,237.49 ","$2,237.49 ","$2,237.49 ",$901.11 ,"$1,467.20 ",$733.60 ,"$2,200.81 ","$1,834.01 ","$1,956.27 ","$2,029.63 "
Hoopeston Regional Hlth Center,8980636,insulin glargine (U-100) 100 unit/mL subcutaneous solution,88222033,J1815,636,"$1,622.99 ","$1,622.99 ",$454.44 ,"$1,485.04 ","$1,136.09 ","$1,358.44 ","$1,485.04 ","$1,485.04 ","$1,485.04 ",$598.07 ,$973.79 ,$486.90 ,"$1,460.69 ","$1,217.24 ","$1,298.39 ","$1,347.08 "
Hoopeston Regional Hlth Center,8980636,levalbuteroL concentrate 1.25 mg/0.5 mL solution for nebulization,93414756,J7612,636,$31.60 ,$31.60 ,$8.85 ,$28.91 ,$22.12 ,$26.45 ,$28.91 ,$28.91 ,$28.91 ,$11.64 ,$18.96 ,$9.48 ,$28.44 ,$23.70 ,$25.28 ,$26.23
Hoopeston Regional Hlth Center,8980636,cycloSPORINE modified 100 mg capsule,93574265,J7502,636,$27.39 ,$27.39 ,$7.67 ,$25.06 ,$19.17 ,$22.93 ,$25.06 ,$25.06 ,$25.06 ,$10.09 ,$16.43 ,$8.22 ,$24.65 ,$20.54 ,$21.91 ,$22.73
Hoopeston Regional Hlth Center,8980636,letrozole 2.5 mg tablet,93762056,J8499,636,$71.62 ,$71.62 ,$20.05 ,$65.53 ,$50.13 ,$59.95 ,$65.53 ,$65.53 ,$65.53 ,$26.39 ,$42.97 ,$21.49 ,$64.46 ,$53.72 ,$57.30 ,$59.44
Hoopeston Regional Hlth Center,8980636,haloperidol lactate 5 mg/mL injection solution,143950125,J1630,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,phentolamine 5 mg injection solution,143956410,J2760,636,"$1,994.61 ","$1,994.61 ",$558.49 ,"$1,825.07 ","$1,396.23 ","$1,669.49 ","$1,825.07 ","$1,825.07 ","$1,825.07 ",$735.01 ,"$1,196.77 ",$598.38 ,"$1,795.15 ","$1,495.96 ","$1,595.69 ","$1,655.53 "
Hoopeston Regional Hlth Center,8980636,"cyanocobalamin (vit B-12) 1,000 mcg/mL injection solution",143962101,J3420,636,$51.73 ,$51.73 ,$14.48 ,$47.33 ,$36.21 ,$43.30 ,$47.33 ,$47.33 ,$47.33 ,$19.06 ,$31.04 ,$15.52 ,$46.56 ,$38.80 ,$41.38 ,$42.94
Hoopeston Regional Hlth Center,8980636,irinotecan 100 mg/5 mL intravenous solution,143970101,J9206,636,$488.92 ,$488.92 ,$136.90 ,$447.36 ,$342.24 ,$409.23 ,$447.36 ,$447.36 ,$447.36 ,$180.17 ,$293.35 ,$146.68 ,$440.03 ,$366.69 ,$391.14 ,$405.80
Hoopeston Regional Hlth Center,8980636,benztropine 1 mg/mL injection solution,143972905,J0515,636,$212.08 ,$212.08 ,$59.38 ,$194.05 ,$148.46 ,$177.51 ,$194.05 ,$194.05 ,$194.05 ,$78.15 ,$127.25 ,$63.62 ,$190.87 ,$159.06 ,$169.66 ,$176.03
Hoopeston Regional Hlth Center,8980636,terbutaline 1 mg/mL subcutaneous solution,143974610,J3105,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,cefuroxime sodium 1.5 gram intravenous solution,143997722,J0697,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,INSULIN REGULAR HUMAN 100 UNIT/ML INJECTION,169183311,J1815,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,insulin U-100 regular human 100 unit/mL injection solution,169183311,J1815,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,insulin NPH isophane U-100 human 100 unit/mL subcutaneous suspension,169183411,J1815,636,$965.10 ,$965.10 ,$270.23 ,$883.07 ,$675.57 ,$807.79 ,$883.07 ,$883.07 ,$883.07 ,$355.64 ,$579.06 ,$289.53 ,$868.59 ,$723.83 ,$772.08 ,$801.03
Hoopeston Regional Hlth Center,8980636,insulin aspar prot-insulin aspart 100 unit/mL (70-30) subcutaneous pen,169369619,J1815,636,$645.97 ,$645.97 ,$180.87 ,$591.06 ,$452.18 ,$540.68 ,$591.06 ,$591.06 ,$591.06 ,$238.04 ,$387.58 ,$193.79 ,$581.37 ,$484.48 ,$516.78 ,$536.16
Hoopeston Regional Hlth Center,8980636,INSULIN ASPART 100 UNIT/ML SUB-Q PEN,169633910,J1815,636,$645.97 ,$645.97 ,$180.87 ,$591.06 ,$452.18 ,$540.68 ,$591.06 ,$591.06 ,$591.06 ,$238.04 ,$387.58 ,$193.79 ,$581.37 ,$484.48 ,$516.78 ,$536.16
Hoopeston Regional Hlth Center,8980636,Insulin Aspart 100 unit/mL Sub-Q,169750111,J1815,636,"$1,655.42 ","$1,655.42 ",$463.52 ,"$1,514.71 ","$1,158.79 ","$1,385.59 ","$1,514.71 ","$1,514.71 ","$1,514.71 ",$610.02 ,$993.25 ,$496.63 ,"$1,489.88 ","$1,241.57 ","$1,324.34 ","$1,374.00 "
Hoopeston Regional Hlth Center,8980636,hydrOXYzine pamoate 25 mg capsule,185067401,Q0177,636,$3.72 ,$3.72 ,$1.04 ,$3.40 ,$2.60 ,$3.11 ,$3.40 ,$3.40 ,$3.40 ,$1.37 ,$2.23 ,$1.12 ,$3.35 ,$2.79 ,$2.98 ,$3.09
Hoopeston Regional Hlth Center,8980636,piperacillin-tazobactam 4.5 gram intravenous solution,206885508,J2543,636,$130.87 ,$130.87 ,$36.64 ,$119.75 ,$91.61 ,$109.54 ,$119.75 ,$119.75 ,$119.75 ,$48.23 ,$78.52 ,$39.26 ,$117.78 ,$98.15 ,$104.70 ,$108.62
Hoopeston Regional Hlth Center,8980636,piperacillin-tazobactam 2.25 gram/50 mL in dextrose(iso) IV piggyback,206886001,J2543,636,$108.74 ,$108.74 ,$30.45 ,$99.50 ,$76.12 ,$91.02 ,$99.50 ,$99.50 ,$99.50 ,$40.07 ,$65.24 ,$32.62 ,$97.87 ,$81.56 ,$86.99 ,$90.25
Hoopeston Regional Hlth Center,8980636,piperacillin-tazobactam 2.25 gram/50 mL in dextrose(iso) IV piggyback,206886002,J2543,636,$108.74 ,$108.74 ,$30.45 ,$99.50 ,$76.12 ,$91.02 ,$99.50 ,$99.50 ,$99.50 ,$40.07 ,$65.24 ,$32.62 ,$97.87 ,$81.56 ,$86.99 ,$90.25
Hoopeston Regional Hlth Center,8980636,piperacillin-tazobactam 4.5 gram/100 mL dextrose(iso-osm) IV piggyback,206886202,J2543,636,$179.16 ,$179.16 ,$50.16 ,$163.93 ,$125.41 ,$149.96 ,$163.93 ,$163.93 ,$163.93 ,$66.02 ,$107.50 ,$53.75 ,$161.24 ,$134.37 ,$143.33 ,$148.70
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous solution,264151032,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous solution,264751020,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,"heparin (porcine) 25,000 unit/250 mL (100 unit/mL) in dextrose 5 % IV",264958720,J1644,636,$113.50 ,$113.50 ,$31.78 ,$103.85 ,$79.45 ,$95.00 ,$103.85 ,$103.85 ,$103.85 ,$41.82 ,$68.10 ,$34.05 ,$102.15 ,$85.13 ,$90.80 ,$94.21
Hoopeston Regional Hlth Center,8980636,moxetumomab pasudotox-tdfk 1 mg intravenous solution,310470001,,636,"$9,003.39 ","$9,003.39 ","$2,520.95 ","$8,238.10 ","$6,302.37 ","$7,535.84 ","$8,238.10 ","$8,238.10 ","$8,238.10 ","$3,317.75 ","$5,402.03 ","$2,701.02 ","$8,103.05 ","$6,752.54 ","$7,202.71 ","$7,472.81 "
Hoopeston Regional Hlth Center,8980636,sodium chloride 3 % intravenous injection solution,338005403,J7040,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,lidocaine (PF) 4 mg/mL (0.4 %) in 5 % dextrose intravenous solution,338040903,J2001,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,gentamicin 80 mg/100 mL in sodium chloride(iso) intravenous piggyback,338050348,J1580,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,gentamicin 100 mg/100 mL in sodium chloride(iso) intravenous piggyback,338050548,J1580,636,$47.17 ,$47.17 ,$13.21 ,$43.16 ,$33.02 ,$39.48 ,$43.16 ,$43.16 ,$43.16 ,$17.38 ,$28.30 ,$14.15 ,$42.45 ,$35.38 ,$37.74 ,$39.15
Hoopeston Regional Hlth Center,8980636,fat emulsion 20 % intravenous,338051913,B4185,636,$245.81 ,$245.81 ,$68.83 ,$224.92 ,$172.07 ,$205.74 ,$224.92 ,$224.92 ,$224.92 ,$90.58 ,$147.49 ,$73.74 ,$221.23 ,$184.36 ,$196.65 ,$204.02
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous piggyback,338055111,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous piggyback,338055118,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,potassium chloride 10 mEq/100mL in sterile water intravenous piggyback,338070948,J3480,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,ceFAZolin 1 gram/50 mL in dextrose (iso-osmotic) intravenous piggyback,338350341,J0690,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,prochlorperazine maleate 10 mg tablet,378511001,Q0164,636,$6.50 ,$6.50 ,$1.82 ,$5.95 ,$4.55 ,$5.44 ,$5.95 ,$5.95 ,$5.95 ,$2.40 ,$3.90 ,$1.95 ,$5.85 ,$4.88 ,$5.20 ,$5.40
Hoopeston Regional Hlth Center,8980636,pentostatin 10 mg intravenous solution,409080101,J9268,636,"$12,463.44 ","$12,463.44 ","$3,489.76 ","$11,404.05 ","$8,724.41 ","$10,431.90 ","$11,404.05 ","$11,404.05 ","$11,404.05 ","$4,592.78 ","$7,478.06 ","$3,739.03 ","$11,217.10 ","$9,347.58 ","$9,970.75 ","$10,344.66 "
Hoopeston Regional Hlth Center,8980636,ceFAZolin 1 gram solution for injection,409080501,J0690,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,mepivacaine (PF) 10 mg/mL (1 %) injection solution,409103630,J0670,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"meperidine (PF) 25 mg/mL injection solution,meperidine (PF) 25 mg/mL injection syringe",409117630,J2175,636,$47.58 ,$47.58 ,$13.32 ,$43.54 ,$33.31 ,$39.82 ,$43.54 ,$43.54 ,$43.54 ,$17.53 ,$28.55 ,$14.27 ,$42.82 ,$35.69 ,$38.06 ,$39.49
Hoopeston Regional Hlth Center,8980636,"meperidine (PF) 50 mg/mL injection solution,meperidine (PF) 50 mg/mL injection syringe",409117830,J2175,636,$48.99 ,$48.99 ,$13.72 ,$44.83 ,$34.29 ,$41.00 ,$44.83 ,$44.83 ,$44.83 ,$18.05 ,$29.39 ,$14.70 ,$44.09 ,$36.74 ,$39.19 ,$40.66
Hoopeston Regional Hlth Center,8980636,meperidine (PF) 75 mg/mL injection syringe,409117930,J2175,636,$50.05 ,$50.05 ,$14.01 ,$45.80 ,$35.04 ,$41.89 ,$45.80 ,$45.80 ,$45.80 ,$18.44 ,$30.03 ,$15.02 ,$45.05 ,$37.54 ,$40.04 ,$41.54
Hoopeston Regional Hlth Center,8980636,diazePAM 5 mg/mL injection syringe,409127332,J3360,636,$102.01 ,$102.01 ,$28.56 ,$93.34 ,$71.41 ,$85.38 ,$93.34 ,$93.34 ,$93.34 ,$37.59 ,$61.21 ,$30.60 ,$91.81 ,$76.51 ,$81.61 ,$84.67
Hoopeston Regional Hlth Center,8980636,"HYDROmorphone (PF) 1 mg/mL injection syringe,HYDROmorphone 1 mg/mL injection syringe,HYDROmorphone 1 mg/mL injection solution,HYDROmorphone (PF) 1 mg/mL injection solution",409128331,J1170,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"HYDROmorphone 2 mg/mL injection syringe,HYDROmorphone (PF) 2 mg/mL injection solution,HYDROmorphone (PF) 2 mg/mL injection syringe,HYDROmorphone 2 mg/mL injection solution",409131230,J1170,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"heparin, porcine (PF) 5,000 unit/0.5 mL injection syringe",409131632,J1644,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,lidocaine (PF) 100 mg/5 mL (2 %) intravenous syringe,409132305,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,nalbuphine 10 mg/mL injection solution,409146301,J2300,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,nalbuphine 20 mg/mL injection solution,409146501,J2300,636,$47.11 ,$47.11 ,$13.19 ,$43.11 ,$32.98 ,$39.43 ,$43.11 ,$43.11 ,$43.11 ,$17.36 ,$28.27 ,$14.13 ,$42.40 ,$35.33 ,$37.69 ,$39.10
Hoopeston Regional Hlth Center,8980636,atropine 0.1 mg/mL injection syringe,409163010,J0461,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection syringe,409175410,J3475,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"morphine 2 mg/mL intravenous syringe,morphine 2 mg/mL injection syringe,morphine 2 mg/mL injection solution",409189001,J2270,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"morphine 2 mg/mL Syringe,morphine 2 mg/mL injection syringe,morphine 2 mg/mL injection solution",409189001,J2270,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"morphine 4 mg/mL injection solution,morphine 4 mg/mL injection syringe,morphine 4 mg/mL intravenous solution, morphine 4 mg/mL intravenous syringe",409189101,J2270,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,morphine 4 mg/mL intravenous syringe,409189101,J2270,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,morphine 4 mg/mL Syringe,409189101,J2270,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"morphine 4 mg/mL Syringe,morphine 4 mg/mL injection solution,morphine 4 mg/mL injection syringe,morphine 4 mg/mL intravenous solution",409189101,J2270,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"morphine 10 mg/mL intravenous syringe,morphine 10 mg/mL intravenous solution,morphine 10 mg/mL injection syringe",409189301,J2270,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"morphine 10 mg/ml Syringe, morphine 10 mg/mL intravenous solution,morphine 10 mg/mL injection syringe",409189301,J2270,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,procainamide 100 mg/mL injection solution,409190201,J2690,636,$641.28 ,$641.28 ,$179.56 ,$586.77 ,$448.90 ,$536.75 ,$586.77 ,$586.77 ,$586.77 ,$236.31 ,$384.77 ,$192.38 ,$577.15 ,$480.96 ,$513.02 ,$532.26
Hoopeston Regional Hlth Center,8980636,procainamide 500 mg/mL injection solution,409190301,J2690,636,$466.93 ,$466.93 ,$130.74 ,$427.24 ,$326.85 ,$390.82 ,$427.24 ,$427.24 ,$427.24 ,$172.06 ,$280.16 ,$140.08 ,$420.24 ,$350.20 ,$373.54 ,$387.55
Hoopeston Regional Hlth Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",409198530,J2060,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,DOBUTamine 250 mg/20 mL (12.5 mg/mL) intravenous solution,409202520,J1250,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,morphine (PF) 30 mg/30 mL PCA intravenous solution,409202902,J2274,636,$145.61 ,$145.61 ,$40.77 ,$133.23 ,$101.93 ,$121.88 ,$133.23 ,$133.23 ,$133.23 ,$53.66 ,$87.37 ,$43.68 ,$131.05 ,$109.21 ,$116.49 ,$120.86
Hoopeston Regional Hlth Center,8980636,midazolam (PF) 5 mg/mL injection solution,409230802,,636,$145.61 ,$145.61 ,$40.77 ,$133.23 ,$101.93 ,$121.88 ,$133.23 ,$133.23 ,$133.23 ,$53.66 ,$87.37 ,$43.68 ,$131.05 ,$109.21 ,$116.49 ,$120.86
Hoopeston Regional Hlth Center,8980636,DOBUTamine 250 mg/250 mL (1 mg/mL) in 5 % dextrose intravenous,409234632,J1250,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,"DOBUTamine 500 mg/250 mL (2,000 mcg/mL) in 5 % dextrose IV",409234732,J1250,636,$103.32 ,$103.32 ,$28.93 ,$94.54 ,$72.32 ,$86.48 ,$94.54 ,$94.54 ,$94.54 ,$38.07 ,$61.99 ,$31.00 ,$92.99 ,$77.49 ,$82.66 ,$85.76
Hoopeston Regional Hlth Center,8980636,midazolam 5 mg/mL injection solution,409259605,J2250,636,$145.61 ,$145.61 ,$40.77 ,$133.23 ,$101.93 ,$121.88 ,$133.23 ,$133.23 ,$133.23 ,$53.66 ,$87.37 ,$43.68 ,$131.05 ,$109.21 ,$116.49 ,$120.86
Hoopeston Regional Hlth Center,8980636,ampicillin-sulbactam 3 gram intravenous solution,409298703,J0295,636,$98.82 ,$98.82 ,$27.67 ,$90.42 ,$69.17 ,$82.71 ,$90.42 ,$90.42 ,$90.42 ,$36.42 ,$59.29 ,$29.65 ,$88.94 ,$74.12 ,$79.06 ,$82.02
Hoopeston Regional Hlth Center,8980636,piperacillin-tazobactam 2.25 gram intravenous solution,409337402,J2543,636,$94.63 ,$94.63 ,$26.50 ,$86.59 ,$66.24 ,$79.21 ,$86.59 ,$86.59 ,$86.59 ,$34.87 ,$56.78 ,$28.39 ,$85.17 ,$70.97 ,$75.70 ,$78.54
Hoopeston Regional Hlth Center,8980636,piperacillin-tazobactam 4.5 gram intravenous solution,409337904,J2543,636,$142.82 ,$142.82 ,$39.99 ,$130.68 ,$99.97 ,$119.54 ,$130.68 ,$130.68 ,$130.68 ,$52.63 ,$85.69 ,$42.85 ,$128.54 ,$107.12 ,$114.26 ,$118.54
Hoopeston Regional Hlth Center,8980636,metoclopramide 5 mg/mL injection solution,409341401,J2765,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,tobramycin 40 mg/mL injection solution,409357801,J3260,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,ketorolac 15 mg/mL injection solution,409379301,J1885,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,Morphine (PF) 1 mg/mL Injection,409381512,,636,$57.73 ,$57.73 ,$16.16 ,$52.82 ,$40.41 ,$48.32 ,$52.82 ,$52.82 ,$52.82 ,$21.27 ,$34.64 ,$17.32 ,$51.96 ,$43.30 ,$46.18 ,$47.92
Hoopeston Regional Hlth Center,8980636,morphine (PF) 1 mg/mL injection solution,409381512,,636,$57.73 ,$57.73 ,$16.16 ,$52.82 ,$40.41 ,$48.32 ,$52.82 ,$52.82 ,$52.82 ,$21.27 ,$34.64 ,$17.32 ,$51.96 ,$43.30 ,$46.18 ,$47.92
Hoopeston Regional Hlth Center,8980636,mannitoL 25 % intravenous solution,409403101,J2150,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,lidocaine HCL 10 mg/mL (1 %) injection solution,409427601,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,lidocaine HCL 10 mg/mL (1 %) injection solution,409427602,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,lidocaine HCL 20 mg/mL (2 %) injection solution,409427702,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,lidocaine (PF) 40 mg/mL (4 %) injection solution,409428301,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,LIDOCAINE HCL (PF) 40 MG/ML INJECTION,409428301,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % injection solution,409488810,J7040,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,cefTAZidime 1 gram intravenous solution,409509216,J0713,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,DOPamine 200 mg/5 mL (40 mg/mL) intravenous solution,409582001,J1265,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,aminophylline 250 mg/10 mL intravenous solution,409592101,J0280,636,$122.25 ,$122.25 ,$34.23 ,$111.86 ,$85.58 ,$102.32 ,$111.86 ,$111.86 ,$111.86 ,$45.05 ,$73.35 ,$36.68 ,$110.03 ,$91.69 ,$97.80 ,$101.47
Hoopeston Regional Hlth Center,8980636,aminophylline 500 mg/20 mL intravenous solution,409592201,J0280,636,$91.17 ,$91.17 ,$25.53 ,$83.42 ,$63.82 ,$76.31 ,$83.42 ,$83.42 ,$83.42 ,$33.60 ,$54.70 ,$27.35 ,$82.05 ,$68.38 ,$72.94 ,$75.67
Hoopeston Regional Hlth Center,8980636,meperidine 10 mg/mL injection cartridge,409603004,J2175,636,$64.14 ,$64.14 ,$17.96 ,$58.69 ,$44.90 ,$53.69 ,$58.69 ,$58.69 ,$58.69 ,$23.64 ,$38.48 ,$19.24 ,$57.73 ,$48.11 ,$51.31 ,$53.24
Hoopeston Regional Hlth Center,8980636,erythromycin lactobionate 500 mg intravenous solution,409647644,J1364,636,$532.11 ,$532.11 ,$148.99 ,$486.88 ,$372.48 ,$445.38 ,$486.88 ,$486.88 ,$486.88 ,$196.08 ,$319.27 ,$159.63 ,$478.90 ,$399.08 ,$425.69 ,$441.65
Hoopeston Regional Hlth Center,8980636,"vancomycin 1,000 mg intravenous injection",409653501,J3370,636,$179.89 ,$179.89 ,$50.37 ,$164.60 ,$125.92 ,$150.57 ,$164.60 ,$164.60 ,$164.60 ,$66.29 ,$107.93 ,$53.97 ,$161.90 ,$134.92 ,$143.91 ,$149.31
Hoopeston Regional Hlth Center,8980636,succinylcholine chloride 20 mg/mL injection solution,409662902,J0330,636,$137.38 ,$137.38 ,$38.47 ,$125.70 ,$96.17 ,$114.99 ,$125.70 ,$125.70 ,$125.70 ,$50.62 ,$82.43 ,$41.21 ,$123.64 ,$103.04 ,$109.90 ,$114.03
Hoopeston Regional Hlth Center,8980636,potassium chloride 2 mEq/mL intravenous solution,409665305,J3480,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,magnesium sulfate 20 gram/500 mL (4 %) in water intravenous solution,409672903,J3475,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,magnesium sulfate 4 gram/100 mL (4 %) in water intravenous piggyback,409672923,J3475,636,$54.03 ,$54.03 ,$15.13 ,$49.44 ,$37.82 ,$45.22 ,$49.44 ,$49.44 ,$49.44 ,$19.91 ,$32.42 ,$16.21 ,$48.63 ,$40.52 ,$43.22 ,$44.84
Hoopeston Regional Hlth Center,8980636,magnesium sulfate 4 gram/50 mL (8 %) in water intravenous piggyback,409673013,J3475,636,$55.20 ,$55.20 ,$15.46 ,$50.51 ,$38.64 ,$46.20 ,$50.51 ,$50.51 ,$50.51 ,$20.34 ,$33.12 ,$16.56 ,$49.68 ,$41.40 ,$44.16 ,$45.82
Hoopeston Regional Hlth Center,8980636,potassium chloride 20 mEq/100mL in sterile water intravenous piggyback,409707526,J3480,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous piggyback,409710066,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous piggyback,409710067,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % intravenous piggyback,409710102,J7050,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,potassium chloride 20 mEq/L in 0.9 % sodium chloride intravenous,409711509,J3480,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,potassium chloride 40 mEq/L in 0.9 % sodium chloride intravenous,409711609,J3480,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.45 % intravenous piggyback,409713266,J7040,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.45 % intravenous piggyback,409713267,J7040,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,EPINEPHrine 1 mg/mL (1 mL) injection solution,409724101,J0171,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,cefTRIAXone 2 gram intravenous solution,409733604,J0696,636,$90.08 ,$90.08 ,$25.22 ,$82.42 ,$63.06 ,$75.40 ,$82.42 ,$82.42 ,$82.42 ,$33.19 ,$54.05 ,$27.02 ,$81.07 ,$67.56 ,$72.06 ,$74.77
Hoopeston Regional Hlth Center,8980636,dextran 40 10 % in 5 % dextrose intravenous,409741803,J7100,636,$197.89 ,$197.89 ,$55.41 ,$181.07 ,$138.52 ,$165.63 ,$181.07 ,$181.07 ,$181.07 ,$72.92 ,$118.73 ,$59.37 ,$178.10 ,$148.42 ,$158.31 ,$164.25
Hoopeston Regional Hlth Center,8980636,dextran 40 10 % in 0.9 % sodium chloride intravenous solution,409741903,J7100,636,$203.71 ,$203.71 ,$57.04 ,$186.39 ,$142.60 ,$170.51 ,$186.39 ,$186.39 ,$186.39 ,$75.07 ,$122.23 ,$61.11 ,$183.34 ,$152.78 ,$162.97 ,$169.08
Hoopeston Regional Hlth Center,8980636,"heparin (porcine) (PF) 1,000 unit/500 mL in 0.9 % sodium chloride IV",409762003,J1644,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,"heparin (porcine) 25,000 unit/250 mL in 0.45 % sodium chloride IV soln",409765052,J1644,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,mannitoL 20 % intravenous solution,409771503,J2150,636,$14.55 ,$14.55 ,$4.07 ,$13.31 ,$10.19 ,$12.18 ,$13.31 ,$13.31 ,$13.31 ,$5.36 ,$8.73 ,$4.37 ,$13.10 ,$10.91 ,$11.64 ,$12.08
Hoopeston Regional Hlth Center,8980636,"DOPamine 400 mg/250 mL (1,600 mcg/mL) in 5 % dextrose intravenous soln",409780922,J1265,636,$106.23 ,$106.23 ,$29.74 ,$97.20 ,$74.36 ,$88.91 ,$97.20 ,$97.20 ,$97.20 ,$39.15 ,$63.74 ,$31.87 ,$95.61 ,$79.67 ,$84.98 ,$88.17
Hoopeston Regional Hlth Center,8980636,potassium chloride 20 mEq/L in 5 % dextrose intravenous solution,409790509,J3480,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,potassium chloride 40 mEq/L in 5 % dextrose intravenous solution,409790609,J3480,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous solution,409792225,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous solution,409792230,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous solution,409792248,J7070,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous solution,409792261,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous solution,409792323,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous solution,409792336,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % in water (D5W) intravenous solution,409792337,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % and 0.2 % sodium chloride intravenous solution,409792409,J7042,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % and 0.45 % sodium chloride intravenous solution,409792609,J7042,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 %-0.45 % sodium chloride IV,409792609,J7042,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % and lactated ringers intravenous solution,409792909,J7120,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 10 % in water (D10W) intravenous solution,409793003,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 10 % in water (D10W) intravenous solution,409793009,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,dextrose 5 % and 0.9 % sodium chloride intravenous solution,409794109,J7042,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,lactated Ringers intravenous solution,409795303,J7120,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % IV,409798302,J7050,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,Sodium Chloride 0.9 % IV,409798303,J7040,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % IV,409798309,J7030,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.45 % intravenous solution,409798503,J7040,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.45 % intravenous solution,409798509,J7040,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909418,J3010,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909431,J3010,636,$145.61 ,$145.61 ,$40.77 ,$133.23 ,$101.93 ,$121.88 ,$133.23 ,$133.23 ,$133.23 ,$53.66 ,$87.37 ,$43.68 ,$131.05 ,$109.21 ,$116.49 ,$120.86
Hoopeston Regional Hlth Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,409909461,J3010,636,$176.68 ,$176.68 ,$49.47 ,$161.66 ,$123.68 ,$147.88 ,$161.66 ,$161.66 ,$161.66 ,$65.11 ,$106.01 ,$53.00 ,$159.01 ,$132.51 ,$141.34 ,$146.64
Hoopeston Regional Hlth Center,8980636,"phytonadione (vitamin K1) 1 mg/0.5 mL injection solution,phytonadione (vitamin K1) 1 mg/0.5 mL injection syringe",409915701,,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"phytonadione (vitamin K1) 1 mg/0.5 mL injection solution,phytonadione (vitamin K1) 1 mg/0.5 mL injection syringe",409915731,,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,furosemide 10 mg/mL injection syringe,409963104,J1940,636,$81.09 ,$81.09 ,$22.71 ,$74.20 ,$56.76 ,$67.87 ,$74.20 ,$74.20 ,$74.20 ,$29.88 ,$48.65 ,$24.33 ,$72.98 ,$60.82 ,$64.87 ,$67.30
Hoopeston Regional Hlth Center,8980636,ceftaroline fosamiL 600 mg intravenous solution,456060010,J0712,636,"$1,248.53 ","$1,248.53 ",$349.59 ,"$1,142.40 ",$873.97 ,"$1,045.02 ","$1,142.40 ","$1,142.40 ","$1,142.40 ",$460.08 ,$749.12 ,$374.56 ,"$1,123.68 ",$936.40 ,$998.82 ,"$1,036.28 "
Hoopeston Regional Hlth Center,8980636,tacrolimus 5 mg/mL intravenous solution,469301601,J7525,636,"$1,261.58 ","$1,261.58 ",$353.24 ,"$1,154.35 ",$883.11 ,"$1,055.94 ","$1,154.35 ","$1,154.35 ","$1,154.35 ",$464.89 ,$756.95 ,$378.47 ,"$1,135.42 ",$946.19 ,"$1,009.26 ","$1,047.11 "
Hoopeston Regional Hlth Center,8980636,regadenoson 0.4 mg/5 mL intravenous syringe,469650189,J2785,636,"$1,436.73 ","$1,436.73 ",$402.28 ,"$1,314.61 ","$1,005.71 ","$1,202.54 ","$1,314.61 ","$1,314.61 ","$1,314.61 ",$529.44 ,$862.04 ,$431.02 ,"$1,293.06 ","$1,077.55 ","$1,149.38 ","$1,192.49 "
Hoopeston Regional Hlth Center,8980636,albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization,487950101,J7613,636,$2.89 ,$2.89 ,$0.81 ,$2.64 ,$2.02 ,$2.42 ,$2.64 ,$2.64 ,$2.64 ,$1.06 ,$1.73 ,$0.87 ,$2.60 ,$2.17 ,$2.31 ,$2.40
Hoopeston Regional Hlth Center,8980636,albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization,487950103,J7613,636,$4.20 ,$4.20 ,$1.18 ,$3.84 ,$2.94 ,$3.52 ,$3.84 ,$3.84 ,$3.84 ,$1.55 ,$2.52 ,$1.26 ,$3.78 ,$3.15 ,$3.36 ,$3.49
Hoopeston Regional Hlth Center,8980636,budesonide 0.25 mg/2 mL suspension for nebulization,487960101,,636,$46.54 ,$46.54 ,$13.03 ,$42.58 ,$32.58 ,$38.95 ,$42.58 ,$42.58 ,$42.58 ,$17.15 ,$27.92 ,$13.96 ,$41.89 ,$34.91 ,$37.23 ,$38.63
Hoopeston Regional Hlth Center,8980636,ipratropium bromide 0.02 % solution for inhalation,487980101,J7644,636,$3.51 ,$3.51 ,$0.98 ,$3.21 ,$2.46 ,$2.94 ,$3.21 ,$3.21 ,$3.21 ,$1.29 ,$2.11 ,$1.05 ,$3.16 ,$2.63 ,$2.81 ,$2.91
Hoopeston Regional Hlth Center,8980636,methylene blue (antidote) 5 mg/mL (0.5 %) intravenous solution,517037401,Q9968,636,"$1,665.36 ","$1,665.36 ",$466.30 ,"$1,523.80 ","$1,165.75 ","$1,393.91 ","$1,523.80 ","$1,523.80 ","$1,523.80 ",$613.69 ,$999.22 ,$499.61 ,"$1,498.82 ","$1,249.02 ","$1,332.29 ","$1,382.25 "
Hoopeston Regional Hlth Center,8980636,methylene blue (antidote) 5 mg/mL (0.5 %) intravenous solution,517037405,Q9968,636,"$1,665.36 ","$1,665.36 ",$466.30 ,"$1,523.80 ","$1,165.75 ","$1,393.91 ","$1,523.80 ","$1,523.80 ","$1,523.80 ",$613.69 ,$999.22 ,$499.61 ,"$1,498.82 ","$1,249.02 ","$1,332.29 ","$1,382.25 "
Hoopeston Regional Hlth Center,8980636,atropine 0.4 mg/mL injection solution,517040125,J0461,636,$59.27 ,$59.27 ,$16.60 ,$54.23 ,$41.49 ,$49.61 ,$54.23 ,$54.23 ,$54.23 ,$21.84 ,$35.56 ,$17.78 ,$53.34 ,$44.45 ,$47.42 ,$49.19
Hoopeston Regional Hlth Center,8980636,ferric carboxymaltose 50 mg iron/mL intravenous solution,517065001,J1439,636,"$6,825.29 ","$6,825.29 ","$1,911.08 ","$6,245.14 ","$4,777.70 ","$5,712.77 ","$6,245.14 ","$6,245.14 ","$6,245.14 ","$2,515.12 ","$4,095.17 ","$2,047.59 ","$6,142.76 ","$5,118.97 ","$5,460.23 ","$5,664.99 "
Hoopeston Regional Hlth Center,8980636,betamethasone acetate and sodium phos 6 mg/mL suspension for injection,517072001,J0702,636,$75.34 ,$75.34 ,$21.10 ,$68.94 ,$52.74 ,$63.06 ,$68.94 ,$68.94 ,$68.94 ,$27.76 ,$45.20 ,$22.60 ,$67.81 ,$56.51 ,$60.27 ,$62.53
Hoopeston Regional Hlth Center,8980636,atropine 1 mg/mL Injection,517101025,J0461,636,$91.12 ,$91.12 ,$25.51 ,$83.37 ,$63.78 ,$76.27 ,$83.37 ,$83.37 ,$83.37 ,$33.58 ,$54.67 ,$27.34 ,$82.01 ,$68.34 ,$72.90 ,$75.63
Hoopeston Regional Hlth Center,8980636,iron sucrose 100 mg iron/5 mL intravenous solution,517234010,J1756,636,$227.01 ,$227.01 ,$63.56 ,$207.71 ,$158.91 ,$190.01 ,$207.71 ,$207.71 ,$207.71 ,$83.65 ,$136.21 ,$68.10 ,$204.31 ,$170.26 ,$181.61 ,$188.42
Hoopeston Regional Hlth Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,517360525,,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,papaverine 30 mg/mL injection solution,517400225,J2440,636,$902.57 ,$902.57 ,$252.72 ,$825.85 ,$631.80 ,$755.45 ,$825.85 ,$825.85 ,$825.85 ,$332.60 ,$541.54 ,$270.77 ,$812.31 ,$676.93 ,$722.06 ,$749.13
Hoopeston Regional Hlth Center,8980636,acetylcysteine 200 mg/mL (20 %) solution,517763003,J7608,636,$58.25 ,$58.25 ,$16.31 ,$53.30 ,$40.78 ,$48.76 ,$53.30 ,$53.30 ,$53.30 ,$21.47 ,$34.95 ,$17.48 ,$52.43 ,$43.69 ,$46.60 ,$48.35
Hoopeston Regional Hlth Center,8980636,Acetylsysteine 20 % (200 mg/mL) Soln,517763003,J7608,636,$58.25 ,$58.25 ,$16.31 ,$53.30 ,$40.78 ,$48.76 ,$53.30 ,$53.30 ,$53.30 ,$21.47 ,$34.95 ,$17.48 ,$52.43 ,$43.69 ,$46.60 ,$48.35
Hoopeston Regional Hlth Center,8980636,droperidol 2.5 mg/mL Injection,517970225,J1790,636,$60.67 ,$60.67 ,$16.99 ,$55.51 ,$42.47 ,$50.78 ,$55.51 ,$55.51 ,$55.51 ,$22.36 ,$36.40 ,$18.20 ,$54.60 ,$45.50 ,$48.54 ,$50.36
Hoopeston Regional Hlth Center,8980636,enoxaparin 40 mg/0.4 mL subcutaneous syringe,548560200,J1650,636,$45.30 ,$45.30 ,$12.68 ,$41.45 ,$31.71 ,$37.92 ,$41.45 ,$41.45 ,$41.45 ,$16.69 ,$27.18 ,$13.59 ,$40.77 ,$33.98 ,$36.24 ,$37.60
Hoopeston Regional Hlth Center,8980636,cosyntropin 0.25 mg solution for injection,548590000,J0834,636,$660.07 ,$660.07 ,$184.82 ,$603.96 ,$462.05 ,$552.48 ,$603.96 ,$603.96 ,$603.96 ,$243.24 ,$396.04 ,$198.02 ,$594.06 ,$495.05 ,$528.06 ,$547.86
Hoopeston Regional Hlth Center,8980636,"rho(D) immune globulin 1,500 unit (300 mcg) intramuscular syringe",562780500,J2790,636,$563.63 ,$563.63 ,$157.82 ,$515.72 ,$394.54 ,$471.76 ,$515.72 ,$515.72 ,$515.72 ,$207.70 ,$338.18 ,$169.09 ,$507.27 ,$422.72 ,$450.90 ,$467.81
Hoopeston Regional Hlth Center,8980636,"rho(D) immune globulin 1,500 unit (300 mcg) intramuscular syringe",562780525,J2790,636,$563.63 ,$563.63 ,$157.82 ,$515.72 ,$394.54 ,$471.76 ,$515.72 ,$515.72 ,$515.72 ,$207.70 ,$338.18 ,$169.09 ,$507.27 ,$422.72 ,$450.90 ,$467.81
Hoopeston Regional Hlth Center,8980636,rho(D) immune globulin 250 unit (50 mcg) intramuscular syringe,562780601,J2788,636,$346.61 ,$346.61 ,$97.05 ,$317.15 ,$242.63 ,$290.11 ,$317.15 ,$317.15 ,$317.15 ,$127.73 ,$207.97 ,$103.98 ,$311.95 ,$259.96 ,$277.29 ,$287.69
Hoopeston Regional Hlth Center,8980636,dihydroergotamine 1 mg/mL injection solution,574085010,J1110,636,$646.23 ,$646.23 ,$180.94 ,$591.30 ,$452.36 ,$540.89 ,$591.30 ,$591.30 ,$591.30 ,$238.14 ,$387.74 ,$193.87 ,$581.61 ,$484.67 ,$516.98 ,$536.37
Hoopeston Regional Hlth Center,8980636,methylPREDNISolone 4 mg tablet,591079001,J7509,636,$8.99 ,$8.99 ,$2.52 ,$8.23 ,$6.29 ,$7.52 ,$8.23 ,$8.23 ,$8.23 ,$3.31 ,$5.39 ,$2.70 ,$8.09 ,$6.74 ,$7.19 ,$7.46
Hoopeston Regional Hlth Center,8980636,tamoxifen 10 mg tablet,591247218,J8999,636,$13.49 ,$13.49 ,$3.78 ,$12.34 ,$9.44 ,$11.29 ,$12.34 ,$12.34 ,$12.34 ,$4.97 ,$8.09 ,$4.05 ,$12.14 ,$10.12 ,$10.79 ,$11.20
Hoopeston Regional Hlth Center,8980636,perphenazine 2 mg tablet,591410101,Q0175,636,$10.47 ,$10.47 ,$2.93 ,$9.58 ,$7.33 ,$8.76 ,$9.58 ,$9.58 ,$9.58 ,$3.86 ,$6.28 ,$3.14 ,$9.42 ,$7.85 ,$8.38 ,$8.69
Hoopeston Regional Hlth Center,8980636,"glucagon (human recombinant) 1 mg/mL solution for injection,glucagon HCL 1 mg/mL solution for injection,glucagon HCL 1 mg solution for injection,glucagon 1 mg solution for injection",597005301,J1610,636,$842.86 ,$842.86 ,$236.00 ,$771.22 ,$590.00 ,$705.47 ,$771.22 ,$771.22 ,$771.22 ,$310.59 ,$505.72 ,$252.86 ,$758.57 ,$632.15 ,$674.29 ,$699.57
Hoopeston Regional Hlth Center,8980636,"glucagon (human recombinant) 1 mg/mL solution for injection,glucagon HCL 1 mg/mL solution for injection,glucagon HCL 1 mg solution for injection,glucagon 1 mg solution for injection",597005345,J1610,636,$842.86 ,$842.86 ,$236.00 ,$771.22 ,$590.00 ,$705.47 ,$771.22 ,$771.22 ,$771.22 ,$310.59 ,$505.72 ,$252.86 ,$758.57 ,$632.15 ,$674.29 ,$699.57
Hoopeston Regional Hlth Center,8980636,predniSONE 20 mg tablet,603533932,,636,$3.49 ,$3.49 ,$0.98 ,$3.19 ,$2.44 ,$2.92 ,$3.19 ,$3.19 ,$3.19 ,$1.29 ,$2.09 ,$1.05 ,$3.14 ,$2.62 ,$2.79 ,$2.90
Hoopeston Regional Hlth Center,8980636,dexAMETHasone sodium phosphate 10 mg/mL injection solution,641036721,J1100,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,dexAMETHasone sodium phosphate 10 mg/mL injection solution,641036725,J1100,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,PHENobarbital sodium 65 mg/mL injection solution,641047625,J2560,636,$173.30 ,$173.30 ,$48.52 ,$158.57 ,$121.31 ,$145.05 ,$158.57 ,$158.57 ,$158.57 ,$63.86 ,$103.98 ,$51.99 ,$155.97 ,$129.98 ,$138.64 ,$143.84
Hoopeston Regional Hlth Center,8980636,promethazine 25 mg/mL injection solution,641092825,J2550,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,chlorproMAZINE 25 mg/mL injection solution,641139735,J3230,636,$198.87 ,$198.87 ,$55.68 ,$181.97 ,$139.21 ,$166.45 ,$181.97 ,$181.97 ,$181.97 ,$73.28 ,$119.32 ,$59.66 ,$178.98 ,$149.15 ,$159.10 ,$165.06
Hoopeston Regional Hlth Center,8980636,promethazine 50 mg/mL injection solution,641149631,J2550,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,promethazine 50 mg/mL injection solution,641149635,J2550,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,phenytoin sodium 50 mg/mL intravenous solution,641255545,J1165,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,morphine (PF) 0.5 mg/mL injection solution,641602001,,636,$208.07 ,$208.07 ,$58.26 ,$190.38 ,$145.65 ,$174.15 ,$190.38 ,$190.38 ,$190.38 ,$76.67 ,$124.84 ,$62.42 ,$187.26 ,$156.05 ,$166.46 ,$172.70
Hoopeston Regional Hlth Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,641602725,J3010,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,morphine (PF) 10 mg/mL injection solution,641603901,,636,"$1,505.09 ","$1,505.09 ",$421.43 ,"$1,377.16 ","$1,053.56 ","$1,259.76 ","$1,377.16 ","$1,377.16 ","$1,377.16 ",$554.63 ,$903.05 ,$451.53 ,"$1,354.58 ","$1,128.82 ","$1,204.07 ","$1,249.22 "
Hoopeston Regional Hlth Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",641604425,J2060,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"LORazepam 2 mg/mL injection solution,LORazepam 2 mg/mL injection syringe",641604610,J2060,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"meperidine (PF) 100 mg/mL injection solution,meperidine (PF) 100 mg/mL injection syringe",641605401,J2175,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"meperidine (PF) 100 mg/mL injection solution,meperidine (PF) 100 mg/mL injection syringe",641605425,J2175,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,midazolam 1 mg/mL injection solution,641605701,J2250,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,midazolam 1 mg/mL injection solution,641605710,J2250,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,Midazolam 1 mg/mL Injection,641605910,J2250,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,midazolam 1 mg/mL injection solution,641605910,J2250,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,naloxone 0.4 mg/mL injection solution,641613225,J2310,636,$73.24 ,$73.24 ,$20.51 ,$67.01 ,$51.27 ,$61.30 ,$67.01 ,$67.01 ,$67.01 ,$26.99 ,$43.94 ,$21.97 ,$65.92 ,$54.93 ,$58.59 ,$60.79
Hoopeston Regional Hlth Center,8980636,Phenylephrine 10 mg/mL Injection,641614225,J2370,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,phenylephrine 10 mg/mL injection solution,641614225,J2370,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,methylPREDNISolone acetate 80 mg/mL suspension for injection,703005104,J1040,636,$103.27 ,$103.27 ,$28.92 ,$94.49 ,$72.29 ,$86.44 ,$94.49 ,$94.49 ,$94.49 ,$38.05 ,$61.96 ,$30.98 ,$92.94 ,$77.45 ,$82.62 ,$85.71
Hoopeston Regional Hlth Center,8980636,irinotecan 40 mg/2 mL intravenous solution,703443211,J9206,636,$158.46 ,$158.46 ,$44.37 ,$144.99 ,$110.92 ,$132.63 ,$144.99 ,$144.99 ,$144.99 ,$58.39 ,$95.08 ,$47.54 ,$142.61 ,$118.85 ,$126.77 ,$131.52
Hoopeston Regional Hlth Center,8980636,"tacrolimus 0.5 mg capsule, immediate-release",781210201,J7507,636,$12.72 ,$12.72 ,$3.56 ,$11.64 ,$8.90 ,$10.65 ,$11.64 ,$11.64 ,$11.64 ,$4.69 ,$7.63 ,$3.82 ,$11.45 ,$9.54 ,$10.18 ,$10.56
Hoopeston Regional Hlth Center,8980636,OLANZapine 10 mg intramuscular solution,781315972,S0166,636,$85.68 ,$85.68 ,$23.99 ,$78.40 ,$59.98 ,$71.71 ,$78.40 ,$78.40 ,$78.40 ,$31.57 ,$51.41 ,$25.70 ,$77.11 ,$64.26 ,$68.54 ,$71.11
Hoopeston Regional Hlth Center,8980636,glatiramer 20 mg/mL subcutaneous syringe,781323434,J1595,636,$879.59 ,$879.59 ,$246.29 ,$804.82 ,$615.71 ,$736.22 ,$804.82 ,$804.82 ,$804.82 ,$324.13 ,$527.75 ,$263.88 ,$791.63 ,$659.69 ,$703.67 ,$730.06
Hoopeston Regional Hlth Center,8980636,ampicillin 1 gram solution for injection,781340495,J0290,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,ondansetron 8 mg disintegrating tablet,781523964,Q0162,636,$138.11 ,$138.11 ,$38.67 ,$126.37 ,$96.68 ,$115.60 ,$126.37 ,$126.37 ,$126.37 ,$50.89 ,$82.87 ,$41.43 ,$124.30 ,$103.58 ,$110.49 ,$114.63
Hoopeston Regional Hlth Center,8980636,penicillin G potassium 20 million unit solution for injection,781613694,J2540,636,$101.41 ,$101.41 ,$28.39 ,$92.79 ,$70.99 ,$84.88 ,$92.79 ,$92.79 ,$92.79 ,$37.37 ,$60.85 ,$30.42 ,$91.27 ,$76.06 ,$81.13 ,$84.17
Hoopeston Regional Hlth Center,8980636,chlorproMAZINE 10 mg tablet,832030000,Q0161,636,$21.91 ,$21.91 ,$6.13 ,$20.05 ,$15.34 ,$18.34 ,$20.05 ,$20.05 ,$20.05 ,$8.07 ,$13.15 ,$6.57 ,$19.72 ,$16.43 ,$17.53 ,$18.19
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",944049302,P9047,636,$407.60 ,$407.60 ,$114.13 ,$372.95 ,$285.32 ,$341.16 ,$372.95 ,$372.95 ,$372.95 ,$150.20 ,$244.56 ,$122.28 ,$366.84 ,$305.70 ,$326.08 ,$338.31
Hoopeston Regional Hlth Center,8980636,enoxaparin 30 mg/0.3 mL subcutaneous syringe,955100310,J1650,636,$48.20 ,$48.20 ,$13.50 ,$44.10 ,$33.74 ,$40.34 ,$44.10 ,$44.10 ,$44.10 ,$17.76 ,$28.92 ,$14.46 ,$43.38 ,$36.15 ,$38.56 ,$40.01
Hoopeston Regional Hlth Center,8980636,enoxaparin 60 mg/0.6 mL subcutaneous syringe,955100610,J1650,636,$92.96 ,$92.96 ,$26.03 ,$85.06 ,$65.07 ,$77.81 ,$85.06 ,$85.06 ,$85.06 ,$34.26 ,$55.78 ,$27.89 ,$83.66 ,$69.72 ,$74.37 ,$77.16
Hoopeston Regional Hlth Center,8980636,enoxaparin 80 mg/0.8 mL subcutaneous syringe,955100810,J1650,636,$122.78 ,$122.78 ,$34.38 ,$112.34 ,$85.95 ,$102.77 ,$112.34 ,$112.34 ,$112.34 ,$45.24 ,$73.67 ,$36.83 ,$110.50 ,$92.09 ,$98.22 ,$101.91
Hoopeston Regional Hlth Center,8980636,enoxaparin 120 mg/0.8 mL subcutaneous syringe,955101210,J1650,636,$180.71 ,$180.71 ,$50.60 ,$165.35 ,$126.50 ,$151.25 ,$165.35 ,$165.35 ,$165.35 ,$66.59 ,$108.43 ,$54.21 ,$162.64 ,$135.53 ,$144.57 ,$149.99
Hoopeston Regional Hlth Center,8980636,lactated Ringers intravenous solution,990795309,J7120,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,lactated ringers IV,990795309,J7120,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % IV,990798302,J7050,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % IV,990798303,J7040,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % IV,990798309,J7030,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % intravenous solution,990798325,J7050,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % IV,990798420,J7030,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % IV,990798423,J7030,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % IV,990798436,J7040,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,"heparin, porcine (PF) 10 unit/mL intravenous syringe,heparin, porcine (PF) 10 unit/mL intravenous solution",8290306414,J1642,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"heparin, porcine (PF) 100 unit/mL intravenous syringe",8290306513,J1642,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,alteplase 2 mg intra-catheter solution,9999038378,J2997,636,"$1,048.66 ","$1,048.66 ",$293.62 ,$959.52 ,$734.06 ,$877.73 ,$959.52 ,$959.52 ,$959.52 ,$386.43 ,$629.20 ,$314.60 ,$943.79 ,$786.50 ,$838.93 ,$870.39
Hoopeston Regional Hlth Center,8980636,"prednisoLONE sodium phosphate 15 mg/5 mL Oral Soln,prednisoLONE 15 mg/5 mL oral solution",9999040078,,636,$21.02 ,$21.02 ,$5.89 ,$19.23 ,$14.71 ,$17.59 ,$19.23 ,$19.23 ,$19.23 ,$7.75 ,$12.61 ,$6.31 ,$18.92 ,$15.77 ,$16.82 ,$17.45
Hoopeston Regional Hlth Center,8980636,DOBUTamine 250 mg/250 mL (1 mg/mL) in 5 % dextrose intravenous,9999110943,J1250,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,ONDANSETRON HCL 4 MG/5 ML ORAL SOLN,9999400515,,636,$146.58 ,$146.58 ,$41.04 ,$134.12 ,$102.61 ,$122.69 ,$134.12 ,$134.12 ,$134.12 ,$54.01 ,$87.95 ,$43.97 ,$131.92 ,$109.94 ,$117.26 ,$121.66
Hoopeston Regional Hlth Center,8980636,fentaNYL (PF) 50 mcg/mL Injection,9999400559,J3010,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,tobramycin 300 mg/5 mL in 0.225 % nacl,9999401253,J3260,636,$224.42 ,$224.42 ,$62.84 ,$205.34 ,$157.09 ,$187.84 ,$205.34 ,$205.34 ,$205.34 ,$82.70 ,$134.65 ,$67.33 ,$201.98 ,$168.32 ,$179.54 ,$186.27
Hoopeston Regional Hlth Center,8980636,dextrose 5% in water (D5W) IV,9999500985,J7060,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,fentaNYL (PF) 50 mcg/mL injection solution,9999909421,J3010,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,rabies immune globulin (PF) 300 unit/mL intramuscular solution,13533031801,90375,636,"$1,491.60 ","$1,491.60 ",$417.65 ,"$1,364.81 ","$1,044.12 ","$1,248.47 ","$1,364.81 ","$1,364.81 ","$1,364.81 ",$549.65 ,$894.96 ,$447.48 ,"$1,342.44 ","$1,118.70 ","$1,193.28 ","$1,238.03 "
Hoopeston Regional Hlth Center,8980636,rabies immune globulin (PF) 300 unit/mL intramuscular solution,13533031805,90375,636,"$7,457.96 ","$7,457.96 ","$2,088.23 ","$6,824.03 ","$5,220.57 ","$6,242.31 ","$6,824.03 ","$6,824.03 ","$6,824.03 ","$2,748.26 ","$4,474.78 ","$2,237.39 ","$6,712.16 ","$5,593.47 ","$5,966.37 ","$6,190.11 "
Hoopeston Regional Hlth Center,8980636,rabies immune globulin (PF) 150 unit/mL intramuscular solution,13533061810,90375,636,"$7,210.98 ","$7,210.98 ","$2,019.07 ","$6,598.05 ","$5,047.69 ","$6,035.59 ","$6,598.05 ","$6,598.05 ","$6,598.05 ","$2,657.25 ","$4,326.59 ","$2,163.29 ","$6,489.88 ","$5,408.24 ","$5,768.78 ","$5,985.11 "
Hoopeston Regional Hlth Center,8980636,tetanus immune globulin (PF) 250 unit intramuscular syringe,13533063402,,636,"$1,299.77 ","$1,299.77 ",$363.94 ,"$1,189.29 ",$909.84 ,"$1,087.91 ","$1,189.29 ","$1,189.29 ","$1,189.29 ",$478.97 ,$779.86 ,$389.93 ,"$1,169.79 ",$974.83 ,"$1,039.82 ","$1,078.81 "
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",13533069216,P9046,636,$195.46 ,$195.46 ,$54.73 ,$178.85 ,$136.82 ,$163.60 ,$178.85 ,$178.85 ,$178.85 ,$72.03 ,$117.28 ,$58.64 ,$175.91 ,$146.60 ,$156.37 ,$162.23
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",13533069220,P9047,636,$347.65 ,$347.65 ,$97.34 ,$318.10 ,$243.36 ,$290.98 ,$318.10 ,$318.10 ,$318.10 ,$128.11 ,$208.59 ,$104.30 ,$312.89 ,$260.74 ,$278.12 ,$288.55
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",13533069221,P9047,636,$347.65 ,$347.65 ,$97.34 ,$318.10 ,$243.36 ,$290.98 ,$318.10 ,$318.10 ,$318.10 ,$128.11 ,$208.59 ,$104.30 ,$312.89 ,$260.74 ,$278.12 ,$288.55
Hoopeston Regional Hlth Center,8980636,"alpha-1-proteinase inhibitor (human) 1,000 mg intravenous solution",13533070211,J0256,636,$34.95 ,$34.95 ,$9.79 ,$31.98 ,$24.47 ,$29.25 ,$31.98 ,$31.98 ,$31.98 ,$12.88 ,$20.97 ,$10.49 ,$31.46 ,$26.21 ,$27.96 ,$29.01
Hoopeston Regional Hlth Center,8980636,"alpha-1-proteinase inhibitor (human) 1,000 mg intravenous solution",13533070310,J0256,636,$34.95 ,$34.95 ,$9.79 ,$31.98 ,$24.47 ,$29.25 ,$31.98 ,$31.98 ,$31.98 ,$12.88 ,$20.97 ,$10.49 ,$31.46 ,$26.21 ,$27.96 ,$29.01
Hoopeston Regional Hlth Center,8980636,immune globu G 5 gram/50 mL(10 %)-gly-IgA ave 46 mcg/mL injection soln,13533080020,J1561,636,"$4,547.07 ","$4,547.07 ","$1,273.18 ","$4,160.57 ","$3,182.95 ","$3,805.90 ","$4,160.57 ","$4,160.57 ","$4,160.57 ","$1,675.60 ","$2,728.24 ","$1,364.12 ","$4,092.36 ","$3,410.30 ","$3,637.66 ","$3,774.07 "
Hoopeston Regional Hlth Center,8980636,immune glob G 20 gram/200 mL(10%)-gly-IgA ave 46 mcg/mL injection soln,13533080024,J1561,636,"$18,178.10 ","$18,178.10 ","$5,089.87 ","$16,632.96 ","$12,724.67 ","$15,215.07 ","$16,632.96 ","$16,632.96 ","$16,632.96 ","$6,698.63 ","$10,906.86 ","$5,453.43 ","$16,360.29 ","$13,633.58 ","$14,542.48 ","$15,087.82 "
Hoopeston Regional Hlth Center,8980636,immune glob G 10 gram/100 mL(10%)-gly-IgA ave 46 mcg/mL injection soln,13533080071,J1561,636,"$9,090.75 ","$9,090.75 ","$2,545.41 ","$8,318.04 ","$6,363.53 ","$7,608.96 ","$8,318.04 ","$8,318.04 ","$8,318.04 ","$3,349.94 ","$5,454.45 ","$2,727.23 ","$8,181.68 ","$6,818.06 ","$7,272.60 ","$7,545.32 "
Hoopeston Regional Hlth Center,8980636,anastrozole 1 mg tablet,16729003510,J8999,636,$54.71 ,$54.71 ,$15.32 ,$50.06 ,$38.30 ,$45.79 ,$50.06 ,$50.06 ,$50.06 ,$20.16 ,$32.83 ,$16.41 ,$49.24 ,$41.03 ,$43.77 ,$45.41
Hoopeston Regional Hlth Center,8980636,eptifibatide 0.75 mg/mL intravenous solution,16729025938,J1327,636,"$3,423.23 ","$3,423.23 ",$958.50 ,"$3,132.26 ","$2,396.26 ","$2,865.24 ","$3,132.26 ","$3,132.26 ","$3,132.26 ","$1,261.46 ","$2,053.94 ","$1,026.97 ","$3,080.91 ","$2,567.42 ","$2,738.58 ","$2,841.28 "
Hoopeston Regional Hlth Center,8980636,methylene blue (antidote) 1 % (10 mg/mL) intravenous solution,17478050401,Q9968,636,$120.59 ,$120.59 ,$33.77 ,$110.34 ,$84.41 ,$100.93 ,$110.34 ,$110.34 ,$110.34 ,$44.44 ,$72.35 ,$36.18 ,$108.53 ,$90.44 ,$96.47 ,$100.09
Hoopeston Regional Hlth Center,8980636,ePHEDrine sulfate 50 mg/mL injection solution,17478051500,J3490,636,$283.27 ,$283.27 ,$79.32 ,$259.19 ,$198.29 ,$237.10 ,$259.19 ,$259.19 ,$259.19 ,$104.38 ,$169.96 ,$84.98 ,$254.94 ,$212.45 ,$226.62 ,$235.11
Hoopeston Regional Hlth Center,8980636,adenosine 3 mg/mL intravenous solution,17478054202,,636,$46.69 ,$46.69 ,$13.07 ,$42.72 ,$32.68 ,$39.08 ,$42.72 ,$42.72 ,$42.72 ,$17.21 ,$28.01 ,$14.01 ,$42.02 ,$35.02 ,$37.35 ,$38.75
Hoopeston Regional Hlth Center,8980636,"hyaluronidase, human recombinant 150 unit/mL injection solution",18657011704,J3473,636,$349.36 ,$349.36 ,$97.82 ,$319.66 ,$244.55 ,$292.41 ,$319.66 ,$319.66 ,$319.66 ,$128.74 ,$209.62 ,$104.81 ,$314.42 ,$262.02 ,$279.49 ,$289.97
Hoopeston Regional Hlth Center,8980636,flu vaccine qs 2021-22(6mos up)(PF) 60 mcg(15 mcgx4)/0.5 mL IM syringe,19515081841,90686,636,$38.67 ,$38.67 ,$10.83 ,$35.38 ,$27.07 ,$32.37 ,$35.38 ,$35.38 ,$35.38 ,$14.25 ,$23.20 ,$11.60 ,$34.80 ,$29.00 ,$30.94 ,$32.10
Hoopeston Regional Hlth Center,8980636,flu vaccine qs 2021-22(6mos up)(PF) 60 mcg(15 mcgx4)/0.5 mL IM syringe,19515081852,90686,636,$38.67 ,$38.67 ,$10.83 ,$35.38 ,$27.07 ,$32.37 ,$35.38 ,$35.38 ,$35.38 ,$14.25 ,$23.20 ,$11.60 ,$34.80 ,$29.00 ,$30.94 ,$32.10
Hoopeston Regional Hlth Center,8980636,amikacin 500 mg/2 mL Injection,23155029031,J0278,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,prochlorperazine Edisylate 10 mg/2 mL (5 mg/mL) injection solution,23155029442,J0780,636,$132.60 ,$132.60 ,$37.13 ,$121.33 ,$92.82 ,$110.99 ,$121.33 ,$121.33 ,$121.33 ,$48.86 ,$79.56 ,$39.78 ,$119.34 ,$99.45 ,$106.08 ,$110.06
Hoopeston Regional Hlth Center,8980636,cefTRIAXone 1 gram solution for injection,25021010610,J0696,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,cefTRIAXone 1 gram solution for injection,25021010667,J0696,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,cefTRIAXone 2 gram solution for injection,25021010720,J0696,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,cefepime 1 gram solution for injection,25021012120,J0692,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,cefepime 2 gram solution for injection,25021012250,J0692,636,$104.79 ,$104.79 ,$29.34 ,$95.88 ,$73.35 ,$87.71 ,$95.88 ,$95.88 ,$95.88 ,$38.62 ,$62.87 ,$31.44 ,$94.31 ,$78.59 ,$83.83 ,$86.98
Hoopeston Regional Hlth Center,8980636,ampicillin-sulbactam 1.5 gram solution for injection,25021014220,J0295,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,linezolid in 5% dextrose in water 600 mg/300 mL intravenous piggyback,25021016987,J2020,636,$247.84 ,$247.84 ,$69.40 ,$226.77 ,$173.49 ,$207.44 ,$226.77 ,$226.77 ,$226.77 ,$91.33 ,$148.70 ,$74.35 ,$223.06 ,$185.88 ,$198.27 ,$205.71
Hoopeston Regional Hlth Center,8980636,"heparin, porcine (PF) 1,000 unit/mL injection solution",25021040102,J1644,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,"heparin (porcine) 10,000 unit/mL injection solution",25021040304,J1644,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"heparin (porcine) 20,000 unit/mL injection solution",25021040401,J1644,636,$104.79 ,$104.79 ,$29.34 ,$95.88 ,$73.35 ,$87.71 ,$95.88 ,$95.88 ,$95.88 ,$38.62 ,$62.87 ,$31.44 ,$94.31 ,$78.59 ,$83.83 ,$86.98
Hoopeston Regional Hlth Center,8980636,orphenadrine citrate 30 mg/mL injection solution,25021065102,J2360,636,$87.21 ,$87.21 ,$24.42 ,$79.80 ,$61.05 ,$72.99 ,$79.80 ,$79.80 ,$79.80 ,$32.14 ,$52.33 ,$26.16 ,$78.49 ,$65.41 ,$69.77 ,$72.38
Hoopeston Regional Hlth Center,8980636,PENTobarbital sodium 50 mg/mL injection solution,25021067620,J2515,636,"$6,054.74 ","$6,054.74 ","$1,695.33 ","$5,540.09 ","$4,238.32 ","$5,067.82 ","$5,540.09 ","$5,540.09 ","$5,540.09 ","$2,231.17 ","$3,632.84 ","$1,816.42 ","$5,449.27 ","$4,541.06 ","$4,843.79 ","$5,025.43 "
Hoopeston Regional Hlth Center,8980636,ibandronate 3 mg/3 mL intravenous syringe,25021082761,J1740,636,"$1,172.14 ","$1,172.14 ",$328.20 ,"$1,072.51 ",$820.50 ,$981.08 ,"$1,072.51 ","$1,072.51 ","$1,072.51 ",$431.93 ,$703.28 ,$351.64 ,"$1,054.93 ",$879.11 ,$937.71 ,$972.88
Hoopeston Regional Hlth Center,8980636,mepivacaine (PF) 30 mg/mL (3 %) injection cartridge,31382075305,J0670,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,ciprofloxacin 400 mg/200 mL in 5 % dextrose intravenous piggyback,36000000924,J0744,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,ondansetron HCl (PF) 4 mg/2 mL injection solution,36000001225,J2405,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,levoFLOXacin 250 mg/50 mL in 5 % dextrose intravenous piggyback,36000004624,J1956,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,levoFLOXacin 500 mg/100 mL in 5 % dextrose intravenous piggyback,36000004724,J1956,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,levoFLOXacin 750 mg/150 mL in 5 % dextrose intravenous piggyback,36000004824,J1956,636,$48.80 ,$48.80 ,$13.66 ,$44.65 ,$34.16 ,$40.85 ,$44.65 ,$44.65 ,$44.65 ,$17.98 ,$29.28 ,$14.64 ,$43.92 ,$36.60 ,$39.04 ,$40.50
Hoopeston Regional Hlth Center,8980636,furosemide 10 mg/mL injection solution,36000028225,J1940,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,furosemide 10 mg/mL injection solution,36000028325,J1940,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,furosemide 10 mg/mL injection solution,36000028425,J1940,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,tobramycin 1.2 gram solution for injection,39822041206,J3260,636,$500.95 ,$500.95 ,$140.27 ,$458.37 ,$350.67 ,$419.30 ,$458.37 ,$458.37 ,$458.37 ,$184.60 ,$300.57 ,$150.29 ,$450.86 ,$375.71 ,$400.76 ,$415.79
Hoopeston Regional Hlth Center,8980636,tuberculin PPD 5 tub. unit/0.1 mL intradermal injection solution,42023010401,86580,636,$19.76 ,$19.76 ,$5.53 ,$18.08 ,$13.83 ,$16.54 ,$18.08 ,$18.08 ,$18.08 ,$7.28 ,$11.86 ,$5.93 ,$17.78 ,$14.82 ,$15.81 ,$16.40
Hoopeston Regional Hlth Center,8980636,estradiol valerate 40 mg/mL intramuscular oil,42023011201,J1380,636,"$1,776.01 ","$1,776.01 ",$497.28 ,"$1,625.05 ","$1,243.21 ","$1,486.52 ","$1,625.05 ","$1,625.05 ","$1,625.05 ",$654.46 ,"$1,065.61 ",$532.80 ,"$1,598.41 ","$1,332.01 ","$1,420.81 ","$1,474.09 "
Hoopeston Regional Hlth Center,8980636,oxytocin 10 unit/mL injection solution,42023011625,J2590,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,EPINEPHrine 1 mg/mL injection solution,42023016801,J0171,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,ertapenem 1 gram solution for injection,42023022110,J1335,636,$718.73 ,$718.73 ,$201.24 ,$657.64 ,$503.11 ,$601.58 ,$657.64 ,$657.64 ,$657.64 ,$264.85 ,$431.24 ,$215.62 ,$646.86 ,$539.05 ,$574.98 ,$596.55
Hoopeston Regional Hlth Center,8980636,mogamulizumab-kpkc 4 mg/mL intravenous solution,42747076101,,636,"$16,767.25 ","$16,767.25 ","$4,694.83 ","$15,342.03 ","$11,737.08 ","$14,034.19 ","$15,342.03 ","$15,342.03 ","$15,342.03 ","$6,178.73 ","$10,060.35 ","$5,030.18 ","$15,090.53 ","$12,575.44 ","$13,413.80 ","$13,916.82 "
Hoopeston Regional Hlth Center,8980636,"amiodarone 150 mg/100 mL (1.5 mg/mL) in dextrose, iso-osmotic IV",43066015010,J0282,636,$245.51 ,$245.51 ,$68.74 ,$224.64 ,$171.86 ,$205.49 ,$224.64 ,$224.64 ,$224.64 ,$90.47 ,$147.31 ,$73.65 ,$220.96 ,$184.13 ,$196.41 ,$203.77
Hoopeston Regional Hlth Center,8980636,"amiodarone 360 mg/200 mL (1.8 mg/mL) in dextrose, iso-osmotic IV",43066036020,J0282,636,$357.38 ,$357.38 ,$100.07 ,$327.00 ,$250.17 ,$299.13 ,$327.00 ,$327.00 ,$327.00 ,$131.69 ,$214.43 ,$107.21 ,$321.64 ,$268.04 ,$285.90 ,$296.63
Hoopeston Regional Hlth Center,8980636,phytonadione (vitamin K1) 10 mg/mL injection solution,43598040516,J3430,636,$87.99 ,$87.99 ,$24.64 ,$80.51 ,$61.59 ,$73.65 ,$80.51 ,$80.51 ,$80.51 ,$32.42 ,$52.79 ,$26.40 ,$79.19 ,$65.99 ,$70.39 ,$73.03
Hoopeston Regional Hlth Center,8980636,interferon beta-1a (albumin) 44 mcg/0.5 mL subcutaneous syringe,44087004403,Q3028,636,"$3,227.95 ","$3,227.95 ",$903.83 ,"$2,953.57 ","$2,259.57 ","$2,701.79 ","$2,953.57 ","$2,953.57 ","$2,953.57 ","$1,189.50 ","$1,936.77 ",$968.39 ,"$2,905.16 ","$2,420.96 ","$2,582.36 ","$2,679.20 "
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",44206025110,P9047,636,$631.96 ,$631.96 ,$176.95 ,$578.24 ,$442.37 ,$528.95 ,$578.24 ,$578.24 ,$578.24 ,$232.88 ,$379.18 ,$189.59 ,$568.76 ,$473.97 ,$505.57 ,$524.53
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",44206025190,P9047,636,$631.96 ,$631.96 ,$176.95 ,$578.24 ,$442.37 ,$528.95 ,$578.24 ,$578.24 ,$578.24 ,$232.88 ,$379.18 ,$189.59 ,$568.76 ,$473.97 ,$505.57 ,$524.53
Hoopeston Regional Hlth Center,8980636,"albumin, human 5 % intravenous solution",44206031050,P9045,636,$631.96 ,$631.96 ,$176.95 ,$578.24 ,$442.37 ,$528.95 ,$578.24 ,$578.24 ,$578.24 ,$232.88 ,$379.18 ,$189.59 ,$568.76 ,$473.97 ,$505.57 ,$524.53
Hoopeston Regional Hlth Center,8980636,cefTAZidime 1 gram solution for injection,44567023525,J0713,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,magnesium sulfate 1 gram/100 mL in dextrose 5 % intravenous piggyback,44567041024,J3475,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,magnesium sulfate 2 gram/50 mL (4 %) in water intravenous piggyback,44567042024,J3475,636,$50.83 ,$50.83 ,$14.23 ,$46.51 ,$35.58 ,$42.54 ,$46.51 ,$46.51 ,$46.51 ,$18.73 ,$30.50 ,$15.25 ,$45.75 ,$38.12 ,$40.66 ,$42.19
Hoopeston Regional Hlth Center,8980636,piperacillin-tazobactam 4.5 gram intravenous solution,44567080310,J2543,636,$137.41 ,$137.41 ,$38.47 ,$125.73 ,$96.19 ,$115.01 ,$125.73 ,$125.73 ,$125.73 ,$50.64 ,$82.45 ,$41.22 ,$123.67 ,$103.06 ,$109.93 ,$114.05
Hoopeston Regional Hlth Center,8980636,voriconazole 200 mg intravenous solution,47781046671,J3465,636,$775.09 ,$775.09 ,$217.03 ,$709.21 ,$542.56 ,$648.75 ,$709.21 ,$709.21 ,$709.21 ,$285.62 ,$465.05 ,$232.53 ,$697.58 ,$581.32 ,$620.07 ,$643.32
Hoopeston Regional Hlth Center,8980636,rabies immune globulin (PF) 150 unit/mL intramuscular solution,49281019020,90376,636,"$1,825.45 ","$1,825.45 ",$511.13 ,"$1,670.29 ","$1,277.82 ","$1,527.90 ","$1,670.29 ","$1,670.29 ","$1,670.29 ",$672.68 ,"$1,095.27 ",$547.64 ,"$1,642.91 ","$1,369.09 ","$1,460.36 ","$1,515.12 "
Hoopeston Regional Hlth Center,8980636,tetanus and diphtheria tox (PF) 5 Lf unit-2 Lf unit/0.5 mL IM syringe,49281021515,90714,636,$79.84 ,$79.84 ,$22.36 ,$73.05 ,$55.89 ,$66.83 ,$73.05 ,$73.05 ,$73.05 ,$29.42 ,$47.90 ,$23.95 ,$71.86 ,$59.88 ,$63.87 ,$66.27
Hoopeston Regional Hlth Center,8980636,tetanus and diphtheria tox (PF) 5 Lf unit-2 Lf unit/0.5 mL IM syringe,49281021588,90714,636,$79.84 ,$79.84 ,$22.36 ,$73.05 ,$55.89 ,$66.83 ,$73.05 ,$73.05 ,$73.05 ,$29.42 ,$47.90 ,$23.95 ,$71.86 ,$59.88 ,$63.87 ,$66.27
Hoopeston Regional Hlth Center,8980636,"rabies vaccine,human diploid (PF) 2.5 unit intramuscular solution",49281025051,90675,636,$857.44 ,$857.44 ,$240.08 ,$784.56 ,$600.21 ,$717.68 ,$784.56 ,$784.56 ,$784.56 ,$315.97 ,$514.46 ,$257.23 ,$771.70 ,$643.08 ,$685.95 ,$711.68
Hoopeston Regional Hlth Center,8980636,"diphth,pertus(ac)tetanus(PF)2 Lf-(2.5-5-3-5mcg)-5 Lf/0.5 mL IM syringe",49281040015,90715,636,$97.59 ,$97.59 ,$27.33 ,$89.29 ,$68.31 ,$81.68 ,$89.29 ,$89.29 ,$89.29 ,$35.96 ,$58.55 ,$29.28 ,$87.83 ,$73.19 ,$78.07 ,$81.00
Hoopeston Regional Hlth Center,8980636,"meningoc vac A,C,Y,W-135 dip (PF) 4 mcg/0.5 mL intramuscular solution",49281058905,90734,636,$299.55 ,$299.55 ,$83.87 ,$274.09 ,$209.69 ,$250.72 ,$274.09 ,$274.09 ,$274.09 ,$110.38 ,$179.73 ,$89.87 ,$269.60 ,$224.66 ,$239.64 ,$248.63
Hoopeston Regional Hlth Center,8980636,poliovirus vaccine 40 unit-8 unit-32 unit/0.5 mL injection suspension,49281086010,90713,636,$81.79 ,$81.79 ,$22.90 ,$74.84 ,$57.25 ,$68.46 ,$74.84 ,$74.84 ,$74.84 ,$30.14 ,$49.07 ,$24.54 ,$73.61 ,$61.34 ,$65.43 ,$67.89
Hoopeston Regional Hlth Center,8980636,belimumab 400 mg intravenous solution,49401010201,J0490,636,"$7,990.10 ","$7,990.10 ","$2,237.23 ","$7,310.94 ","$5,593.07 ","$6,687.71 ","$7,310.94 ","$7,310.94 ","$7,310.94 ","$2,944.35 ","$4,794.06 ","$2,397.03 ","$7,191.09 ","$5,992.58 ","$6,392.08 ","$6,631.78 "
Hoopeston Regional Hlth Center,8980636,zidovudine 10 mg/mL intravenous solution,49702021326,J3485,636,$238.77 ,$238.77 ,$66.86 ,$218.47 ,$167.14 ,$199.85 ,$218.47 ,$218.47 ,$218.47 ,$87.99 ,$143.26 ,$71.63 ,$214.89 ,$179.08 ,$191.02 ,$198.18
Hoopeston Regional Hlth Center,8980636,dolutegravir 50 mg tablet,49702022813,J8499,636,$276.49 ,$276.49 ,$77.42 ,$252.99 ,$193.54 ,$231.42 ,$252.99 ,$252.99 ,$252.99 ,$101.89 ,$165.89 ,$82.95 ,$248.84 ,$207.37 ,$221.19 ,$229.49
Hoopeston Regional Hlth Center,8980636,hydroxyurea 500 mg capsule,49884072401,J8999,636,$10.61 ,$10.61 ,$2.97 ,$9.71 ,$7.43 ,$8.88 ,$9.71 ,$9.71 ,$9.71 ,$3.91 ,$6.37 ,$3.18 ,$9.55 ,$7.96 ,$8.49 ,$8.81
Hoopeston Regional Hlth Center,8980636,alteplase 2 mg intra-catheter solution,50242004164,J2997,636,$764.99 ,$764.99 ,$214.20 ,$699.97 ,$535.49 ,$640.30 ,$699.97 ,$699.97 ,$699.97 ,$281.90 ,$458.99 ,$229.50 ,$688.49 ,$573.74 ,$611.99 ,$634.94
Hoopeston Regional Hlth Center,8980636,erlotinib 100 mg tablet,50242006301,J8999,636,"$1,056.57 ","$1,056.57 ",$295.84 ,$966.76 ,$739.60 ,$884.35 ,$966.76 ,$966.76 ,$966.76 ,$389.35 ,$633.94 ,$316.97 ,$950.91 ,$792.43 ,$845.26 ,$876.95
Hoopeston Regional Hlth Center,8980636,erlotinib 150 mg tablet,50242006401,J8999,636,$696.40 ,$696.40 ,$194.99 ,$637.21 ,$487.48 ,$582.89 ,$637.21 ,$637.21 ,$637.21 ,$256.62 ,$417.84 ,$208.92 ,$626.76 ,$522.30 ,$557.12 ,$578.01
Hoopeston Regional Hlth Center,8980636,alteplase 100 mg IV Solution,50242008525,J2997,636,"$24,780.54 ","$24,780.54 ","$6,938.55 ","$22,674.19 ","$17,346.38 ","$20,741.31 ","$22,674.19 ","$22,674.19 ","$22,674.19 ","$9,131.63 ","$14,868.32 ","$7,434.16 ","$22,302.49 ","$18,585.41 ","$19,824.43 ","$20,567.85 "
Hoopeston Regional Hlth Center,8980636,alteplase 100 mg intravenous solution,50242008527,J2997,636,$666.86 ,$666.86 ,$186.72 ,$610.18 ,$466.80 ,$558.16 ,$610.18 ,$610.18 ,$610.18 ,$245.74 ,$400.12 ,$200.06 ,$600.17 ,$500.15 ,$533.49 ,$553.49
Hoopeston Regional Hlth Center,8980636,Alteplase 100 mg IV Solution,50242008527,J2997,636,"$24,780.54 ","$24,780.54 ","$6,938.55 ","$22,674.19 ","$17,346.38 ","$20,741.31 ","$22,674.19 ","$22,674.19 ","$22,674.19 ","$9,131.63 ","$14,868.32 ","$7,434.16 ","$22,302.49 ","$18,585.41 ","$19,824.43 ","$20,567.85 "
Hoopeston Regional Hlth Center,8980636,dornase alfa 1 mg/mL solution for inhalation,50242010040,J7639,636,$490.81 ,$490.81 ,$137.43 ,$449.09 ,$343.57 ,$410.81 ,$449.09 ,$449.09 ,$449.09 ,$180.86 ,$294.49 ,$147.24 ,$441.73 ,$368.11 ,$392.65 ,$407.37
Hoopeston Regional Hlth Center,8980636,tenecteplase 50 mg intravenous solution,50242012047,J3101,636,"$13,703.45 ","$13,703.45 ","$3,836.97 ","$12,538.66 ","$9,592.42 ","$11,469.79 ","$12,538.66 ","$12,538.66 ","$12,538.66 ","$5,049.72 ","$8,222.07 ","$4,111.04 ","$12,333.11 ","$10,277.59 ","$10,962.76 ","$11,373.86 "
Hoopeston Regional Hlth Center,8980636,tocilizumab 80 mg/4 mL (20 mg/mL) intravenous solution,50242013501,J3262,636,"$2,642.88 ","$2,642.88 ",$740.01 ,"$2,418.24 ","$1,850.02 ","$2,212.09 ","$2,418.24 ","$2,418.24 ","$2,418.24 ",$973.90 ,"$1,585.73 ",$792.86 ,"$2,378.59 ","$1,982.16 ","$2,114.30 ","$2,193.59 "
Hoopeston Regional Hlth Center,8980636,tocilizumab 200 mg/10 mL (20 mg/mL) intravenous solution,50242013601,J3262,636,"$6,511.09 ","$6,511.09 ","$1,823.11 ","$5,957.65 ","$4,557.76 ","$5,449.78 ","$5,957.65 ","$5,957.65 ","$5,957.65 ","$2,399.34 ","$3,906.65 ","$1,953.33 ","$5,859.98 ","$4,883.32 ","$5,208.87 ","$5,404.20 "
Hoopeston Regional Hlth Center,8980636,tocilizumab 400 mg/20 mL (20 mg/mL) intravenous solution,50242013701,J3262,636,"$12,958.10 ","$12,958.10 ","$3,628.27 ","$11,856.66 ","$9,070.67 ","$10,845.93 ","$11,856.66 ","$11,856.66 ","$11,856.66 ","$4,775.06 ","$7,774.86 ","$3,887.43 ","$11,662.29 ","$9,718.58 ","$10,366.48 ","$10,755.22 "
Hoopeston Regional Hlth Center,8980636,interferon beta-1b 0.3 mg subcutaneous kit,50419052435,J1830,636,$414.93 ,$414.93 ,$116.18 ,$379.66 ,$290.45 ,$347.30 ,$379.66 ,$379.66 ,$379.66 ,$152.90 ,$248.96 ,$124.48 ,$373.44 ,$311.20 ,$331.94 ,$344.39
Hoopeston Regional Hlth Center,8980636,moxifloxacin 400 mg/250 mL-sodium chloride(iso) intravenous piggyback,50419053701,J2280,636,$374.43 ,$374.43 ,$104.84 ,$342.60 ,$262.10 ,$313.40 ,$342.60 ,$342.60 ,$342.60 ,$137.98 ,$224.66 ,$112.33 ,$336.99 ,$280.82 ,$299.54 ,$310.78
Hoopeston Regional Hlth Center,8980636,certolizumab pegoL 400 mg/2 mL (200 mg/mL x2) subcutaneous syringe kit,50474071079,J0717,636,"$8,492.78 ","$8,492.78 ","$2,377.98 ","$7,770.89 ","$5,944.95 ","$7,108.46 ","$7,770.89 ","$7,770.89 ","$7,770.89 ","$3,129.59 ","$5,095.67 ","$2,547.83 ","$7,643.50 ","$6,369.59 ","$6,794.22 ","$7,049.01 "
Hoopeston Regional Hlth Center,8980636,digoxin immune fab 40 mg intravenous solution,50633012011,J1162,636,"$17,409.49 ","$17,409.49 ","$4,874.66 ","$15,929.68 ","$12,186.64 ","$14,571.74 ","$15,929.68 ","$15,929.68 ","$15,929.68 ","$6,415.40 ","$10,445.69 ","$5,222.85 ","$15,668.54 ","$13,057.12 ","$13,927.59 ","$14,449.88 "
Hoopeston Regional Hlth Center,8980636,chlorproMAZINE 25 mg tablet,51079051920,Q0161,636,$41.61 ,$41.61 ,$11.65 ,$38.07 ,$29.13 ,$34.83 ,$38.07 ,$38.07 ,$38.07 ,$15.33 ,$24.97 ,$12.48 ,$37.45 ,$31.21 ,$33.29 ,$34.54
Hoopeston Regional Hlth Center,8980636,prochlorperazine maleate 5 mg tablet,51079054120,Q0164,636,$5.19 ,$5.19 ,$1.45 ,$4.75 ,$3.63 ,$4.34 ,$4.75 ,$4.75 ,$4.75 ,$1.91 ,$3.11 ,$1.56 ,$4.67 ,$3.89 ,$4.15 ,$4.31
Hoopeston Regional Hlth Center,8980636,methylergonovine 0.2 mg/mL (1 mL) injection solution,51991014417,J2210,636,$141.40 ,$141.40 ,$39.59 ,$129.38 ,$98.98 ,$118.35 ,$129.38 ,$129.38 ,$129.38 ,$52.11 ,$84.84 ,$42.42 ,$127.26 ,$106.05 ,$113.12 ,$117.36
Hoopeston Regional Hlth Center,8980636,iron dextran 50 mg/mL injection solution,52544093102,J1750,636,$142.06 ,$142.06 ,$39.78 ,$129.98 ,$99.44 ,$118.90 ,$129.98 ,$129.98 ,$129.98 ,$52.35 ,$85.24 ,$42.62 ,$127.85 ,$106.55 ,$113.65 ,$117.91
Hoopeston Regional Hlth Center,8980636,deferoxamine 500 mg solution for injection,52609450506,J0895,636,$125.39 ,$125.39 ,$35.11 ,$114.73 ,$87.77 ,$104.95 ,$114.73 ,$114.73 ,$114.73 ,$46.21 ,$75.23 ,$37.62 ,$112.85 ,$94.04 ,$100.31 ,$104.07
Hoopeston Regional Hlth Center,8980636,EPINEPHrine HCl (PF) 1 mg/mL (1 mL) injection solution,54288010310,J0171,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,levETIRAcetam 500 mg/5 mL intravenous solution,55150017705,,636,$122.25 ,$122.25 ,$34.23 ,$111.86 ,$85.58 ,$102.32 ,$111.86 ,$111.86 ,$111.86 ,$45.05 ,$73.35 ,$36.68 ,$110.03 ,$91.69 ,$97.80 ,$101.47
Hoopeston Regional Hlth Center,8980636,amiodarone 50 mg/mL intravenous solution,55150018003,J0282,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,eptifibatide 0.75 mg/mL intravenous solution,55150021899,J1327,636,"$4,106.50 ","$4,106.50 ","$1,149.82 ","$3,757.45 ","$2,874.55 ","$3,437.14 ","$3,757.45 ","$3,757.45 ","$3,757.45 ","$1,513.25 ","$2,463.90 ","$1,231.95 ","$3,695.85 ","$3,079.88 ","$3,285.20 ","$3,408.40 "
Hoopeston Regional Hlth Center,8980636,acetylcysteine 200 mg/mL (20 %) intravenous solution,55150025930,J0132,636,$102.85 ,$102.85 ,$28.80 ,$94.11 ,$72.00 ,$86.09 ,$94.11 ,$94.11 ,$94.11 ,$37.90 ,$61.71 ,$30.86 ,$92.57 ,$77.14 ,$82.28 ,$85.37
Hoopeston Regional Hlth Center,8980636,zoledronic acid 4 mg/5 mL intravenous solution,55150026605,J3489,636,$419.07 ,$419.07 ,$117.34 ,$383.45 ,$293.35 ,$350.76 ,$383.45 ,$383.45 ,$383.45 ,$154.43 ,$251.44 ,$125.72 ,$377.16 ,$314.30 ,$335.26 ,$347.83
Hoopeston Regional Hlth Center,8980636,darbepoetin alfa 500 mcg/mL in polysorbate injection syringe,55513003201,J0881,636,"$16,304.89 ","$16,304.89 ","$4,565.37 ","$14,918.97 ","$11,413.42 ","$13,647.19 ","$14,918.97 ","$14,918.97 ","$14,918.97 ","$6,008.35 ","$9,782.93 ","$4,891.47 ","$14,674.40 ","$12,228.67 ","$13,043.91 ","$13,533.06 "
Hoopeston Regional Hlth Center,8980636,"epoetin alfa 2,000 unit/mL injection solution",55513012610,J0885,636,$222.76 ,$222.76 ,$62.37 ,$203.83 ,$155.93 ,$186.45 ,$203.83 ,$203.83 ,$203.83 ,$82.09 ,$133.66 ,$66.83 ,$200.48 ,$167.07 ,$178.21 ,$184.89
Hoopeston Regional Hlth Center,8980636,pegfilgrastim 6 mg/0.6 mL subcutaneous syringe,55513019001,,636,"$18,119.44 ","$18,119.44 ","$5,073.44 ","$16,579.29 ","$12,683.61 ","$15,165.97 ","$16,579.29 ","$16,579.29 ","$16,579.29 ","$6,677.01 ","$10,871.66 ","$5,435.83 ","$16,307.50 ","$13,589.58 ","$14,495.55 ","$15,039.14 "
Hoopeston Regional Hlth Center,8980636,filgrastim 300 mcg/mL injection solution,55513053010,J1442,636,"$1,444.44 ","$1,444.44 ",$404.44 ,"$1,321.66 ","$1,011.11 ","$1,209.00 ","$1,321.66 ","$1,321.66 ","$1,321.66 ",$532.28 ,$866.66 ,$433.33 ,"$1,300.00 ","$1,083.33 ","$1,155.55 ","$1,198.89 "
Hoopeston Regional Hlth Center,8980636,filgrastim 480 mcg/1.6 mL injection solution,55513054610,J1442,636,"$2,227.72 ","$2,227.72 ",$623.76 ,"$2,038.36 ","$1,559.40 ","$1,864.60 ","$2,038.36 ","$2,038.36 ","$2,038.36 ",$820.91 ,"$1,336.63 ",$668.32 ,"$2,004.95 ","$1,670.79 ","$1,782.18 ","$1,849.01 "
Hoopeston Regional Hlth Center,8980636,denosumab 60 mg/mL subcutaneous syringe,55513071001,J0897,636,"$5,809.96 ","$5,809.96 ","$1,626.79 ","$5,316.11 ","$4,066.97 ","$4,862.94 ","$5,316.11 ","$5,316.11 ","$5,316.11 ","$2,140.97 ","$3,485.98 ","$1,742.99 ","$5,228.96 ","$4,357.47 ","$4,647.97 ","$4,822.27 "
Hoopeston Regional Hlth Center,8980636,inFLIXimab 100 mg intravenous solution,57894003001,J1745,636,"$6,594.50 ","$6,594.50 ","$1,846.46 ","$6,033.97 ","$4,616.15 ","$5,519.60 ","$6,033.97 ","$6,033.97 ","$6,033.97 ","$2,430.07 ","$3,956.70 ","$1,978.35 ","$5,935.05 ","$4,945.88 ","$5,275.60 ","$5,473.44 "
Hoopeston Regional Hlth Center,8980636,ustekinumab 130 mg/26 mL intravenous solution,57894005427,,636,"$9,900.20 ","$9,900.20 ","$2,772.06 ","$9,058.68 ","$6,930.14 ","$8,286.47 ","$9,058.68 ","$9,058.68 ","$9,058.68 ","$3,648.22 ","$5,940.12 ","$2,970.06 ","$8,910.18 ","$7,425.15 ","$7,920.16 ","$8,217.17 "
Hoopeston Regional Hlth Center,8980636,dalbavancin 500 mg intravenous solution,57970010001,,636,"$9,168.73 ","$9,168.73 ","$2,567.24 ","$8,389.39 ","$6,418.11 ","$7,674.23 ","$8,389.39 ","$8,389.39 ","$8,389.39 ","$3,378.68 ","$5,501.24 ","$2,750.62 ","$8,251.86 ","$6,876.55 ","$7,334.98 ","$7,610.05 "
Hoopeston Regional Hlth Center,8980636,hep B-DP(a)T-polio vacc (PF) 10 mcg-25Lf-25 mcg-10Lf/0.5 mL IM syringe,58160081143,90723,636,$198.94 ,$198.94 ,$55.70 ,$182.03 ,$139.26 ,$166.51 ,$182.03 ,$182.03 ,$182.03 ,$73.31 ,$119.36 ,$59.68 ,$179.05 ,$149.21 ,$159.15 ,$165.12
Hoopeston Regional Hlth Center,8980636,hep B-DP(a)T-polio vacc (PF) 10 mcg-25Lf-25 mcg-10Lf/0.5 mL IM syringe,58160081152,90723,636,$198.94 ,$198.94 ,$55.70 ,$182.03 ,$139.26 ,$166.51 ,$182.03 ,$182.03 ,$182.03 ,$73.31 ,$119.36 ,$59.68 ,$179.05 ,$149.21 ,$159.15 ,$165.12
Hoopeston Regional Hlth Center,8980636,hepatitis A and B virus vaccine(PF)720 ELISA unit-20 mcg/mL IM syringe,58160081552,90636,636,$249.41 ,$249.41 ,$69.83 ,$228.21 ,$174.59 ,$208.76 ,$228.21 ,$228.21 ,$228.21 ,$91.91 ,$149.65 ,$74.82 ,$224.47 ,$187.06 ,$199.53 ,$207.01
Hoopeston Regional Hlth Center,8980636,haemophilus B polysaccharid conj-tetanus tox(PF) 10 mcg/0.5 mL IM soln,58160081811,90648,636,$25.46 ,$25.46 ,$7.13 ,$23.30 ,$17.82 ,$21.31 ,$23.30 ,$23.30 ,$23.30 ,$9.38 ,$15.28 ,$7.64 ,$22.91 ,$19.10 ,$20.37 ,$21.13
Hoopeston Regional Hlth Center,8980636,hepatitis B virus vaccine recomb (PF) 10 mcg/0.5 mL IM syringe,58160082052,90744,636,$56.12 ,$56.12 ,$15.71 ,$51.35 ,$39.28 ,$46.97 ,$51.35 ,$51.35 ,$51.35 ,$20.68 ,$33.67 ,$16.84 ,$50.51 ,$42.09 ,$44.90 ,$46.58
Hoopeston Regional Hlth Center,8980636,hepatitis B virus vaccine recomb (PF) 20 mcg/mL intramuscular susp,58160082111,90746,636,$137.35 ,$137.35 ,$38.46 ,$125.68 ,$96.15 ,$114.96 ,$125.68 ,$125.68 ,$125.68 ,$50.61 ,$82.41 ,$41.21 ,$123.62 ,$103.01 ,$109.88 ,$114.00
Hoopeston Regional Hlth Center,8980636,"hepatitis A vaccine (PF) 1,440 ELISA unit/mL intramuscular syringe",58160082643,90632,636,$163.80 ,$163.80 ,$45.86 ,$149.88 ,$114.66 ,$137.10 ,$149.88 ,$149.88 ,$149.88 ,$60.36 ,$98.28 ,$49.14 ,$147.42 ,$122.85 ,$131.04 ,$135.95
Hoopeston Regional Hlth Center,8980636,"hepatitis A vaccine (PF) 1,440 ELISA unit/mL intramuscular syringe",58160082652,90632,636,$163.80 ,$163.80 ,$45.86 ,$149.88 ,$114.66 ,$137.10 ,$149.88 ,$149.88 ,$149.88 ,$60.36 ,$98.28 ,$49.14 ,$147.42 ,$122.85 ,$131.04 ,$135.95
Hoopeston Regional Hlth Center,8980636,"diphth,pertussis(acell),tetanus 2.5 Lf unit-8 mcg-5 Lf/0.5 mL IM susp",58160084201,90715,636,$96.08 ,$96.08 ,$26.90 ,$87.91 ,$67.26 ,$80.42 ,$87.91 ,$87.91 ,$87.91 ,$35.41 ,$57.65 ,$28.82 ,$86.47 ,$72.06 ,$76.86 ,$79.75
Hoopeston Regional Hlth Center,8980636,"diphth,pertussis(acell),tetanus 2.5 Lf unit-8 mcg-5 Lf/0.5 mL IM susp",58160084211,90715,636,$96.08 ,$96.08 ,$26.90 ,$87.91 ,$67.26 ,$80.42 ,$87.91 ,$87.91 ,$87.91 ,$35.41 ,$57.65 ,$28.82 ,$86.47 ,$72.06 ,$76.86 ,$79.75
Hoopeston Regional Hlth Center,8980636,"diphth,pertussis(acel),tetanus 2.5 Lf unit-8 mcg-5 Lf/0.5mL IM syringe",58160084252,90715,636,$96.08 ,$96.08 ,$26.90 ,$87.91 ,$67.26 ,$80.42 ,$87.91 ,$87.91 ,$87.91 ,$35.41 ,$57.65 ,$28.82 ,$86.47 ,$72.06 ,$76.86 ,$79.75
Hoopeston Regional Hlth Center,8980636,"rotavirus vaccine,live, 89-12 strain G1P(8) 10exp6 CCID50/mL oral susp",58160085101,90681,636,$282.34 ,$282.34 ,$79.06 ,$258.34 ,$197.64 ,$236.32 ,$258.34 ,$258.34 ,$258.34 ,$104.04 ,$169.40 ,$84.70 ,$254.11 ,$211.76 ,$225.87 ,$234.34
Hoopeston Regional Hlth Center,8980636,"meningoc vac A,C,Y,W-135 dip(PF) 10 mcg-5 mcg/0.5 mL intramuscular kit",58160095509,90734,636,$311.21 ,$311.21 ,$87.14 ,$284.76 ,$217.85 ,$260.48 ,$284.76 ,$284.76 ,$284.76 ,$114.68 ,$186.73 ,$93.36 ,$280.09 ,$233.41 ,$248.97 ,$258.30
Hoopeston Regional Hlth Center,8980636,"rabies vaccine, purified chicken embryo cell (PF) 2.5 unit IM susp",58160096412,90675,636,$803.13 ,$803.13 ,$224.88 ,$734.86 ,$562.19 ,$672.22 ,$734.86 ,$734.86 ,$734.86 ,$295.95 ,$481.88 ,$240.94 ,$722.82 ,$602.35 ,$642.50 ,$666.60
Hoopeston Regional Hlth Center,8980636,etanercept 25 mg (1 mL) subcutaneous powder for solution,58406042534,J1438,636,"$3,255.43 ","$3,255.43 ",$911.52 ,"$2,978.72 ","$2,278.80 ","$2,724.79 ","$2,978.72 ","$2,978.72 ","$2,978.72 ","$1,199.63 ","$1,953.26 ",$976.63 ,"$2,929.89 ","$2,441.57 ","$2,604.34 ","$2,702.01 "
Hoopeston Regional Hlth Center,8980636,thyrotropin alfa 0.9 mg intramuscular solution,58468003002,J3240,636,"$7,577.26 ","$7,577.26 ","$2,121.63 ","$6,933.19 ","$5,304.08 ","$6,342.17 ","$6,933.19 ","$6,933.19 ","$6,933.19 ","$2,792.22 ","$4,546.36 ","$2,273.18 ","$6,819.53 ","$5,682.95 ","$6,061.81 ","$6,289.13 "
Hoopeston Regional Hlth Center,8980636,ferumoxytoL 510 mg/17 mL (30 mg/mL) intravenous solution,59338077501,,636,"$6,738.75 ","$6,738.75 ","$1,886.85 ","$6,165.96 ","$4,717.13 ","$5,640.33 ","$6,165.96 ","$6,165.96 ","$6,165.96 ","$2,483.23 ","$4,043.25 ","$2,021.63 ","$6,064.88 ","$5,054.06 ","$5,391.00 ","$5,593.16 "
Hoopeston Regional Hlth Center,8980636,lenalidomide 25 mg capsule,59572042500,J8999,636,"$1,971.03 ","$1,971.03 ",$551.89 ,"$1,803.49 ","$1,379.72 ","$1,649.75 ","$1,803.49 ","$1,803.49 ","$1,803.49 ",$726.32 ,"$1,182.62 ",$591.31 ,"$1,773.93 ","$1,478.27 ","$1,576.82 ","$1,635.95 "
Hoopeston Regional Hlth Center,8980636,"epoetin alfa 10,000 unit/mL injection solution",59676031001,J0885,636,"$1,244.59 ","$1,244.59 ",$348.49 ,"$1,138.80 ",$871.21 ,"$1,041.72 ","$1,138.80 ","$1,138.80 ","$1,138.80 ",$458.63 ,$746.75 ,$373.38 ,"$1,120.13 ",$933.44 ,$995.67 ,"$1,033.01 "
Hoopeston Regional Hlth Center,8980636,"epoetin alfa 20,000 unit/mL injection solution",59676032004,J0885,636,"$1,469.08 ","$1,469.08 ",$411.34 ,"$1,344.21 ","$1,028.36 ","$1,229.62 ","$1,344.21 ","$1,344.21 ","$1,344.21 ",$541.36 ,$881.45 ,$440.72 ,"$1,322.17 ","$1,101.81 ","$1,175.26 ","$1,219.34 "
Hoopeston Regional Hlth Center,8980636,"epoetin alfa 40,000 unit/mL injection solution",59676034001,J0885,636,"$4,611.94 ","$4,611.94 ","$1,291.34 ","$4,219.93 ","$3,228.36 ","$3,860.19 ","$4,219.93 ","$4,219.93 ","$4,219.93 ","$1,699.50 ","$2,767.16 ","$1,383.58 ","$4,150.75 ","$3,458.96 ","$3,689.55 ","$3,827.91 "
Hoopeston Regional Hlth Center,8980636,hepatitis B immune globulin greatr than 312 unit/mL intramuscular soln,59730420201,90371,636,$360.45 ,$360.45 ,$100.93 ,$329.81 ,$252.32 ,$301.70 ,$329.81 ,$329.81 ,$329.81 ,$132.83 ,$216.27 ,$108.14 ,$324.41 ,$270.34 ,$288.36 ,$299.17
Hoopeston Regional Hlth Center,8980636,"hepatitis B immune globulin > 1,560 unit/5 mL intramuscular solution",59730420301,90371,636,$315.71 ,$315.71 ,$88.40 ,$288.87 ,$221.00 ,$264.25 ,$288.87 ,$288.87 ,$288.87 ,$116.34 ,$189.43 ,$94.71 ,$284.14 ,$236.78 ,$252.57 ,$262.04
Hoopeston Regional Hlth Center,8980636,exemestane 25 mg tablet,59762285801,J8999,636,$81.30 ,$81.30 ,$22.76 ,$74.39 ,$56.91 ,$68.05 ,$74.39 ,$74.39 ,$74.39 ,$29.96 ,$48.78 ,$24.39 ,$73.17 ,$60.98 ,$65.04 ,$67.48
Hoopeston Regional Hlth Center,8980636,sodium thiosulfate 12.5 gram/50 mL (250 mg/mL) intravenous solution,60267070550,J3490,636,$626.14 ,$626.14 ,$175.32 ,$572.92 ,$438.30 ,$524.08 ,$572.92 ,$572.92 ,$572.92 ,$230.73 ,$375.68 ,$187.84 ,$563.53 ,$469.61 ,$500.91 ,$519.70
Hoopeston Regional Hlth Center,8980636,irinotecan 100 mg/5 mL intravenous solution,60505612801,J9206,636,$262.35 ,$262.35 ,$73.46 ,$240.05 ,$183.65 ,$219.59 ,$240.05 ,$240.05 ,$240.05 ,$96.68 ,$157.41 ,$78.71 ,$236.12 ,$196.76 ,$209.88 ,$217.75
Hoopeston Regional Hlth Center,8980636,ertapenem 1 gram solution for injection,60505619604,J1335,636,$718.73 ,$718.73 ,$201.24 ,$657.64 ,$503.11 ,$601.58 ,$657.64 ,$657.64 ,$657.64 ,$264.85 ,$431.24 ,$215.62 ,$646.86 ,$539.05 ,$574.98 ,$596.55
Hoopeston Regional Hlth Center,8980636,predniSONE 10 mg tablet,60687013401,,636,$3.32 ,$3.32 ,$0.93 ,$3.04 ,$2.32 ,$2.78 ,$3.04 ,$3.04 ,$3.04 ,$1.22 ,$1.99 ,$1.00 ,$2.99 ,$2.49 ,$2.66 ,$2.76
Hoopeston Regional Hlth Center,8980636,"penicillin G procaine 600,000 unit/mL intramuscular syringe",60793013010,J2510,636,$230.39 ,$230.39 ,$64.51 ,$210.81 ,$161.27 ,$192.84 ,$210.81 ,$210.81 ,$210.81 ,$84.90 ,$138.23 ,$69.12 ,$207.35 ,$172.79 ,$184.31 ,$191.22
Hoopeston Regional Hlth Center,8980636,"penicillin G benzathine 1,200,000 unit/2 mL intramuscular syringe",60793070110,J0561,636,$302.91 ,$302.91 ,$84.81 ,$277.16 ,$212.04 ,$253.54 ,$277.16 ,$277.16 ,$277.16 ,$111.62 ,$181.75 ,$90.87 ,$272.62 ,$227.18 ,$242.33 ,$251.42
Hoopeston Regional Hlth Center,8980636,pralidoxime 1 gram solution for injection,60977014101,J2730,636,"$2,973.03 ","$2,973.03 ",$832.45 ,"$2,720.32 ","$2,081.12 ","$2,488.43 ","$2,720.32 ","$2,720.32 ","$2,720.32 ","$1,095.56 ","$1,783.82 ",$891.91 ,"$2,675.73 ","$2,229.77 ","$2,378.42 ","$2,467.61 "
Hoopeston Regional Hlth Center,8980636,HYDROmorphone 6 mg/30 mL in 0.9 % sodium chloride PCA intravenous soln,61553050269,,636,$357.97 ,$357.97 ,$100.23 ,$327.54 ,$250.58 ,$299.62 ,$327.54 ,$327.54 ,$327.54 ,$131.91 ,$214.78 ,$107.39 ,$322.17 ,$268.48 ,$286.38 ,$297.12
Hoopeston Regional Hlth Center,8980636,fentaNYL (PF) 300 mcg/30 mL (10 mcg/mL) in 0.9 % NaCl PCA inj solution,61553052169,,636,$357.97 ,$357.97 ,$100.23 ,$327.54 ,$250.58 ,$299.62 ,$327.54 ,$327.54 ,$327.54 ,$131.91 ,$214.78 ,$107.39 ,$322.17 ,$268.48 ,$286.38 ,$297.12
Hoopeston Regional Hlth Center,8980636,HYDROmorphone 6 mg/30 mL in 0.9 % sodium chloride PCA intravenous soln,61553070268,,636,$323.05 ,$323.05 ,$90.45 ,$295.59 ,$226.14 ,$270.39 ,$295.59 ,$295.59 ,$295.59 ,$119.04 ,$193.83 ,$96.92 ,$290.75 ,$242.29 ,$258.44 ,$268.13
Hoopeston Regional Hlth Center,8980636,pamidronate 30 mg/10 mL (3 mg/mL) intravenous solution,61703032418,J2430,636,$131.91 ,$131.91 ,$36.93 ,$120.70 ,$92.34 ,$110.41 ,$120.70 ,$120.70 ,$120.70 ,$48.61 ,$79.15 ,$39.57 ,$118.72 ,$98.93 ,$105.53 ,$109.49
Hoopeston Regional Hlth Center,8980636,irinotecan 100 mg/5 mL intravenous solution,61703034909,J9206,636,$191.87 ,$191.87 ,$53.72 ,$175.56 ,$134.31 ,$160.60 ,$175.56 ,$175.56 ,$175.56 ,$70.70 ,$115.12 ,$57.56 ,$172.68 ,$143.90 ,$153.50 ,$159.25
Hoopeston Regional Hlth Center,8980636,cemiplimab-rwlc 50 mg/mL intravenous solution,61755000801,,636,"$39,743.93 ","$39,743.93 ","$11,128.30 ","$36,365.70 ","$27,820.75 ","$33,265.67 ","$36,365.70 ","$36,365.70 ","$36,365.70 ","$14,645.64 ","$23,846.36 ","$11,923.18 ","$35,769.54 ","$29,807.95 ","$31,795.14 ","$32,987.46 "
Hoopeston Regional Hlth Center,8980636,buprenorphine HCL 8 mg sublingual tablet,62756046083,J0571,636,$40.10 ,$40.10 ,$11.23 ,$36.69 ,$28.07 ,$33.56 ,$36.69 ,$36.69 ,$36.69 ,$14.78 ,$24.06 ,$12.03 ,$36.09 ,$30.08 ,$32.08 ,$33.28
Hoopeston Regional Hlth Center,8980636,gentamicin 40 mg/mL injection solution,63323001002,J1580,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,gentamicin 40 mg/mL injection solution,63323001020,J1580,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,oxytocin 10 unit/mL injection solution,63323001230,J2590,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,"cyanocobalamin (vit B-12) 1,000 mcg/mL injection solution",63323004401,J3420,636,$51.66 ,$51.66 ,$14.46 ,$47.27 ,$36.16 ,$43.24 ,$47.27 ,$47.27 ,$47.27 ,$19.04 ,$31.00 ,$15.50 ,$46.49 ,$38.75 ,$41.33 ,$42.88
Hoopeston Regional Hlth Center,8980636,magnesium sulfate 4 mEq/mL (50 %) injection solution,63323006402,J3475,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,ketorolac 30 mg/mL (1 mL) injection solution,63323016201,J1885,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,63323016501,J1100,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,dexAMETHasone sodium phosphate 4 mg/mL injection solution,63323016505,J1100,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,gentamicin sulfate (pediatric) (PF) 20 mg/2 mL injection solution,63323017302,J1580,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,pyridoxine (vitamin B6) 100 mg/mL injection solution,63323018001,J3415,636,$119.12 ,$119.12 ,$33.35 ,$108.99 ,$83.38 ,$99.70 ,$108.99 ,$108.99 ,$108.99 ,$43.90 ,$71.47 ,$35.74 ,$107.21 ,$89.34 ,$95.30 ,$98.87
Hoopeston Regional Hlth Center,8980636,sodium chloride 0.9 % injection solution,63323018620,J7040,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,lidocaine (PF) 20 mg/mL (2 %) intravenous solution,63323020805,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,vancomycin 500 mg intravenous solution,63323022138,J3370,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,protamine 10 mg/mL intravenous solution,63323022905,J2720,636,$89.25 ,$89.25 ,$24.99 ,$81.66 ,$62.48 ,$74.70 ,$81.66 ,$81.66 ,$81.66 ,$32.89 ,$53.55 ,$26.78 ,$80.33 ,$66.94 ,$71.40 ,$74.08
Hoopeston Regional Hlth Center,8980636,protamine 10 mg/mL intravenous solution,63323022930,J2720,636,$54.88 ,$54.88 ,$15.37 ,$50.22 ,$38.42 ,$45.93 ,$50.22 ,$50.22 ,$50.22 ,$20.22 ,$32.93 ,$16.46 ,$49.39 ,$41.16 ,$43.90 ,$45.55
Hoopeston Regional Hlth Center,8980636,methylPREDNISolone sodium succinate 40 mg solution for injection,63323025503,J2920,636,$45.86 ,$45.86 ,$12.84 ,$41.96 ,$32.10 ,$38.38 ,$41.96 ,$41.96 ,$41.96 ,$16.90 ,$27.52 ,$13.76 ,$41.27 ,$34.40 ,$36.69 ,$38.06
Hoopeston Regional Hlth Center,8980636,Propofol 10 mg/mL IV,63323026929,,636,$45.30 ,$45.30 ,$12.68 ,$41.45 ,$31.71 ,$37.92 ,$41.45 ,$41.45 ,$41.45 ,$16.69 ,$27.18 ,$13.59 ,$40.77 ,$33.98 ,$36.24 ,$37.60
Hoopeston Regional Hlth Center,8980636,propofoL 10 mg/mL intravenous emulsion,63323026965,,636,$212.92 ,$212.92 ,$59.62 ,$194.82 ,$149.04 ,$178.21 ,$194.82 ,$194.82 ,$194.82 ,$78.46 ,$127.75 ,$63.88 ,$191.63 ,$159.69 ,$170.34 ,$176.72
Hoopeston Regional Hlth Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) Injection,63323028565,J2795,636,$287.42 ,$287.42 ,$80.48 ,$262.99 ,$201.19 ,$240.57 ,$262.99 ,$262.99 ,$262.99 ,$105.91 ,$172.45 ,$86.23 ,$258.68 ,$215.57 ,$229.94 ,$238.56
Hoopeston Regional Hlth Center,8980636,ropivacaine (PF) 2 mg/mL (0.2 %) injection solution,63323028565,J2795,636,$287.42 ,$287.42 ,$80.48 ,$262.99 ,$201.19 ,$240.57 ,$262.99 ,$262.99 ,$262.99 ,$105.91 ,$172.45 ,$86.23 ,$258.68 ,$215.57 ,$229.94 ,$238.56
Hoopeston Regional Hlth Center,8980636,ropivacaine (PF) 5 mg/mL (0.5 %) injection solution,63323028611,J2795,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,ropivacaine (PF) 5 mg/mL (0.5 %) injection solution,63323028635,J2795,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,ropivacaine (PF) 10 mg/mL (1 %) injection solution,63323028811,J2795,636,$82.67 ,$82.67 ,$23.15 ,$75.64 ,$57.87 ,$69.19 ,$75.64 ,$75.64 ,$75.64 ,$30.46 ,$49.60 ,$24.80 ,$74.40 ,$62.00 ,$66.14 ,$68.62
Hoopeston Regional Hlth Center,8980636,calcium gluconate 100 mg/mL (10 %) intravenous solution,63323031110,J0610,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,ganciclovir sodium 500 mg intravenous solution,63323031510,J1570,636,$608.00 ,$608.00 ,$170.24 ,$556.32 ,$425.60 ,$508.90 ,$556.32 ,$556.32 ,$556.32 ,$224.05 ,$364.80 ,$182.40 ,$547.20 ,$456.00 ,$486.40 ,$504.64
Hoopeston Regional Hlth Center,8980636,acyclovir sodium 50 mg/mL intravenous solution,63323032510,J0133,636,$166.25 ,$166.25 ,$46.55 ,$152.12 ,$116.38 ,$139.15 ,$152.12 ,$152.12 ,$152.12 ,$61.26 ,$99.75 ,$49.88 ,$149.63 ,$124.69 ,$133.00 ,$137.99
Hoopeston Regional Hlth Center,8980636,cefOXitin 1 gram intravenous solution,63323034125,J0694,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,octreotide acetate 50 mcg/mL injection solution,63323036501,J2354,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,octreotide acetate 100 mcg/mL injection solution,63323037601,J2354,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,octreotide acetate 500 mcg/mL injection solution,63323037701,J2354,636,$341.94 ,$341.94 ,$95.74 ,$312.88 ,$239.36 ,$286.20 ,$312.88 ,$312.88 ,$312.88 ,$126.00 ,$205.16 ,$102.58 ,$307.75 ,$256.46 ,$273.55 ,$283.81
Hoopeston Regional Hlth Center,8980636,colistin (colistimethate sodium) 150 mg solution for injection,63323039306,J0770,636,$193.86 ,$193.86 ,$54.28 ,$177.38 ,$135.70 ,$162.26 ,$177.38 ,$177.38 ,$177.38 ,$71.44 ,$116.32 ,$58.16 ,$174.47 ,$145.40 ,$155.09 ,$160.90
Hoopeston Regional Hlth Center,8980636,azithromycin 500 mg intravenous solution,63323039801,J0456,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,azithromycin 500 mg intravenous solution,63323039810,J0456,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,midazolam 1 mg/mL injection solution,63323041112,J2250,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,lidocaine HCL 5 mg/mL (0.5 %) injection solution,63323048457,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,lidocaine HCL 20 mg/mL (2 %) injection solution,63323048627,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,lidocaine (PF) 10 mg/mL (1 %) injection solution,63323049257,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,lidocaine (PF) 20 mg/mL (2 %) injection solution,63323049507,J2001,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,dexAMETHasone sodium phosphate (PF) 10 mg/mL injection solution,63323050601,J1100,636,$47.12 ,$47.12 ,$13.19 ,$43.11 ,$32.98 ,$39.44 ,$43.11 ,$43.11 ,$43.11 ,$17.36 ,$28.27 ,$14.14 ,$42.41 ,$35.34 ,$37.70 ,$39.11
Hoopeston Regional Hlth Center,8980636,meropenem 500 mg intravenous solution,63323050720,J2185,636,$104.79 ,$104.79 ,$29.34 ,$95.88 ,$73.35 ,$87.71 ,$95.88 ,$95.88 ,$95.88 ,$38.62 ,$62.87 ,$31.44 ,$94.31 ,$78.59 ,$83.83 ,$86.98
Hoopeston Regional Hlth Center,8980636,meropenem 1 gram intravenous solution,63323050830,J2185,636,$174.63 ,$174.63 ,$48.90 ,$159.79 ,$122.24 ,$146.17 ,$159.79 ,$159.79 ,$159.79 ,$64.35 ,$104.78 ,$52.39 ,$157.17 ,$130.97 ,$139.70 ,$144.94
Hoopeston Regional Hlth Center,8980636,"heparin (porcine) 25,000 unit/250 mL in 0.45 % sodium chloride IV soln",63323051774,J1644,636,$64.51 ,$64.51 ,$18.06 ,$59.03 ,$45.16 ,$53.99 ,$59.03 ,$59.03 ,$59.03 ,$23.77 ,$38.71 ,$19.35 ,$58.06 ,$48.38 ,$51.61 ,$53.54
Hoopeston Regional Hlth Center,8980636,heparin lock flush (porcine) 100 unit/mL intravenous solution,63323054505,J1642,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,propranoloL 1 mg/mL intravenous solution,63323060401,J1800,636,$73.73 ,$73.73 ,$20.64 ,$67.46 ,$51.61 ,$61.71 ,$67.46 ,$67.46 ,$67.46 ,$27.17 ,$44.24 ,$22.12 ,$66.36 ,$55.30 ,$58.98 ,$61.20
Hoopeston Regional Hlth Center,8980636,hydrALAZINE 20 mg/mL injection solution,63323061401,J0360,636,$94.75 ,$94.75 ,$26.53 ,$86.70 ,$66.33 ,$79.31 ,$86.70 ,$86.70 ,$86.70 ,$34.92 ,$56.85 ,$28.43 ,$85.28 ,$71.06 ,$75.80 ,$78.64
Hoopeston Regional Hlth Center,8980636,diphenhydrAMINE 50 mg/mL injection solution,63323066401,J1200,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,acetylcysteine 200 mg/mL (20 %) solution,63323069404,J7608,636,$73.85 ,$73.85 ,$20.68 ,$67.57 ,$51.70 ,$61.81 ,$67.57 ,$67.57 ,$67.57 ,$27.21 ,$44.31 ,$22.16 ,$66.47 ,$55.39 ,$59.08 ,$61.30
Hoopeston Regional Hlth Center,8980636,Acetylcysteine 10 % (100 mg/ml) Soln,63323069504,,636,$59.54 ,$59.54 ,$16.67 ,$54.48 ,$41.68 ,$49.83 ,$54.48 ,$54.48 ,$54.48 ,$21.94 ,$35.72 ,$17.86 ,$53.59 ,$44.66 ,$47.63 ,$49.42
Hoopeston Regional Hlth Center,8980636,"moxifloxacin 400 mg/250 mL-sodium acet,sul-water intravenous piggyback",63323085074,J2280,636,$338.05 ,$338.05 ,$94.65 ,$309.32 ,$236.64 ,$282.95 ,$309.32 ,$309.32 ,$309.32 ,$124.57 ,$202.83 ,$101.42 ,$304.25 ,$253.54 ,$270.44 ,$280.58
Hoopeston Regional Hlth Center,8980636,tigecycline 50 mg intravenous solution,63323096010,J3243,636,$936.42 ,$936.42 ,$262.20 ,$856.82 ,$655.49 ,$783.78 ,$856.82 ,$856.82 ,$856.82 ,$345.07 ,$561.85 ,$280.93 ,$842.78 ,$702.32 ,$749.14 ,$777.23
Hoopeston Regional Hlth Center,8980636,zoledronic acid 5 mg/100 mL in mannitoL 5 %-water intravenous piggybck,63323096600,J3489,636,"$2,098.60 ","$2,098.60 ",$587.61 ,"$1,920.22 ","$1,469.02 ","$1,756.53 ","$1,920.22 ","$1,920.22 ","$1,920.22 ",$773.33 ,"$1,259.16 ",$629.58 ,"$1,888.74 ","$1,573.95 ","$1,678.88 ","$1,741.84 "
Hoopeston Regional Hlth Center,8980636,tbo-filgrastim 300 mcg/0.5 mL subcutaneous syringe,63459091011,,636,"$1,171.55 ","$1,171.55 ",$328.03 ,"$1,071.97 ",$820.09 ,$980.59 ,"$1,071.97 ","$1,071.97 ","$1,071.97 ",$431.72 ,$702.93 ,$351.47 ,"$1,054.40 ",$878.66 ,$937.24 ,$972.39
Hoopeston Regional Hlth Center,8980636,"heparin, porcine (PF) 100 unit/mL intravenous syringe",63807060055,J1642,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,hum prothrombin cplx (PCC) 4factor 500 unit (400-620 unit) IV solution,63833038602,,636,$36.44 ,$36.44 ,$10.20 ,$33.34 ,$25.51 ,$30.50 ,$33.34 ,$33.34 ,$33.34 ,$13.43 ,$21.86 ,$10.93 ,$32.80 ,$27.33 ,$29.15 ,$30.25
Hoopeston Regional Hlth Center,8980636,"hum prothrombin cplx(PCC)4fact 1,000 unit (800-1,240 unit) IV solution",63833038702,,636,$35.74 ,$35.74 ,$10.01 ,$32.70 ,$25.02 ,$29.91 ,$32.70 ,$32.70 ,$32.70 ,$13.17 ,$21.44 ,$10.72 ,$32.17 ,$26.81 ,$28.59 ,$29.66
Hoopeston Regional Hlth Center,8980636,"hum prothrombin cplx(PCC)4fact 1,000 unit (800-1,240 unit) IV solution",63833039701,,636,$35.74 ,$35.74 ,$10.01 ,$32.70 ,$25.02 ,$29.91 ,$32.70 ,$32.70 ,$32.70 ,$13.17 ,$21.44 ,$10.72 ,$32.17 ,$26.81 ,$28.59 ,$29.66
Hoopeston Regional Hlth Center,8980636,"albumin, human-kjda 5 % intravenous solution",64208251001,P9041,636,$492.28 ,$492.28 ,$137.84 ,$450.44 ,$344.60 ,$412.04 ,$450.44 ,$450.44 ,$450.44 ,$181.41 ,$295.37 ,$147.68 ,$443.05 ,$369.21 ,$393.82 ,$408.59
Hoopeston Regional Hlth Center,8980636,"albumin, human-kjda 5 % intravenous solution",64208251005,P9041,636,$492.28 ,$492.28 ,$137.84 ,$450.44 ,$344.60 ,$412.04 ,$450.44 ,$450.44 ,$450.44 ,$181.41 ,$295.37 ,$147.68 ,$443.05 ,$369.21 ,$393.82 ,$408.59
Hoopeston Regional Hlth Center,8980636,"albumin, human-kjda 25 % intravenous solution",64208251203,P9046,636,$198.95 ,$198.95 ,$55.71 ,$182.04 ,$139.27 ,$166.52 ,$182.04 ,$182.04 ,$182.04 ,$73.31 ,$119.37 ,$59.69 ,$179.06 ,$149.21 ,$159.16 ,$165.13
Hoopeston Regional Hlth Center,8980636,"albumin, human-kjda 25 % intravenous solution",64208251207,P9046,636,$198.95 ,$198.95 ,$55.71 ,$182.04 ,$139.27 ,$166.52 ,$182.04 ,$182.04 ,$182.04 ,$73.31 ,$119.37 ,$59.69 ,$179.06 ,$149.21 ,$159.16 ,$165.13
Hoopeston Regional Hlth Center,8980636,SUMAtriptan 6 mg/0.5 mL subcutaneous solution,64679072801,J3030,636,$419.64 ,$419.64 ,$117.50 ,$383.97 ,$293.75 ,$351.24 ,$383.97 ,$383.97 ,$383.97 ,$154.64 ,$251.78 ,$125.89 ,$377.68 ,$314.73 ,$335.71 ,$348.30
Hoopeston Regional Hlth Center,8980636,vedolizumab 300 mg intravenous solution,64764030020,,636,"$25,497.36 ","$25,497.36 ","$7,139.26 ","$23,330.08 ","$17,848.15 ","$21,341.29 ","$23,330.08 ","$23,330.08 ","$23,330.08 ","$9,395.78 ","$15,298.42 ","$7,649.21 ","$22,947.62 ","$19,123.02 ","$20,397.89 ","$21,162.81 "
Hoopeston Regional Hlth Center,8980636,cocaine 4 % nasal solution,64950036204,,636,"$1,410.81 ","$1,410.81 ",$395.03 ,"$1,290.89 ",$987.57 ,"$1,180.85 ","$1,290.89 ","$1,290.89 ","$1,290.89 ",$519.88 ,$846.49 ,$423.24 ,"$1,269.73 ","$1,058.11 ","$1,128.65 ","$1,170.97 "
Hoopeston Regional Hlth Center,8980636,dimethyl sulfoxide 50 % intravesical solution,67457017750,J1212,636,"$3,480.09 ","$3,480.09 ",$974.43 ,"$3,184.28 ","$2,436.06 ","$2,912.84 ","$3,184.28 ","$3,184.28 ","$3,184.28 ","$1,282.41 ","$2,088.05 ","$1,044.03 ","$3,132.08 ","$2,610.07 ","$2,784.07 ","$2,888.47 "
Hoopeston Regional Hlth Center,8980636,thiamine HCl (vitamin B1) 100 mg/mL injection solution,67457019602,J3411,636,$97.04 ,$97.04 ,$27.17 ,$88.79 ,$67.93 ,$81.22 ,$88.79 ,$88.79 ,$88.79 ,$35.76 ,$58.22 ,$29.11 ,$87.34 ,$72.78 ,$77.63 ,$80.54
Hoopeston Regional Hlth Center,8980636,levETIRAcetam 500 mg/100 mL in sodium chloride (iso-osm) IV piggyback,67457025500,J1953,636,$101.18 ,$101.18 ,$28.33 ,$92.58 ,$70.83 ,$84.69 ,$92.58 ,$92.58 ,$92.58 ,$37.28 ,$60.71 ,$30.35 ,$91.06 ,$75.89 ,$80.94 ,$83.98
Hoopeston Regional Hlth Center,8980636,ampicillin-sulbactam 3 gram solution for injection,67457034910,J0295,636,$124.40 ,$124.40 ,$34.83 ,$113.83 ,$87.08 ,$104.12 ,$113.83 ,$113.83 ,$113.83 ,$45.84 ,$74.64 ,$37.32 ,$111.96 ,$93.30 ,$99.52 ,$103.25
Hoopeston Regional Hlth Center,8980636,"Heparin (Porcine) 5,000 unit/mL Injection",67457037499,J1644,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"heparin (porcine) 5,000 unit/mL injection solution",67457037499,J1644,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"Heparin (Porcine) 1,000 unit/mL Injection",67457038599,J1644,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"heparin (porcine) 1,000 unit/mL injection solution",67457038599,J1644,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,raNITIdine 50 mg/2 mL (25 mg/mL) injection solution,67457039799,J2780,636,$93.44 ,$93.44 ,$26.16 ,$85.50 ,$65.41 ,$78.21 ,$85.50 ,$85.50 ,$85.50 ,$34.43 ,$56.06 ,$28.03 ,$84.10 ,$70.08 ,$74.75 ,$77.56
Hoopeston Regional Hlth Center,8980636,fondaparinux 2.5 mg/0.5 mL subcutaneous solution syringe,67457058210,J1652,636,$313.42 ,$313.42 ,$87.76 ,$286.78 ,$219.39 ,$262.33 ,$286.78 ,$286.78 ,$286.78 ,$115.50 ,$188.05 ,$94.03 ,$282.08 ,$235.07 ,$250.74 ,$260.14
Hoopeston Regional Hlth Center,8980636,fondaparinux 7.5 mg/0.6 mL subcutaneous solution syringe,67457058400,J1652,636,$572.28 ,$572.28 ,$160.24 ,$523.64 ,$400.60 ,$479.00 ,$523.64 ,$523.64 ,$523.64 ,$210.89 ,$343.37 ,$171.68 ,$515.05 ,$429.21 ,$457.82 ,$474.99
Hoopeston Regional Hlth Center,8980636,fondaparinux 7.5 mg/0.6 mL subcutaneous solution syringe,67457058406,J1652,636,$572.28 ,$572.28 ,$160.24 ,$523.64 ,$400.60 ,$479.00 ,$523.64 ,$523.64 ,$523.64 ,$210.89 ,$343.37 ,$171.68 ,$515.05 ,$429.21 ,$457.82 ,$474.99
Hoopeston Regional Hlth Center,8980636,fondaparinux 10 mg/0.8 mL subcutaneous solution syringe,67457058508,J1652,636,$572.28 ,$572.28 ,$160.24 ,$523.64 ,$400.60 ,$479.00 ,$523.64 ,$523.64 ,$523.64 ,$210.89 ,$343.37 ,$171.68 ,$515.05 ,$429.21 ,$457.82 ,$474.99
Hoopeston Regional Hlth Center,8980636,"heparin (porcine) 10,000 unit/mL injection solution",67457060299,J1644,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,DAPTOmycin 500 mg intravenous solution,67457081350,J0878,636,$763.12 ,$763.12 ,$213.67 ,$698.25 ,$534.18 ,$638.73 ,$698.25 ,$698.25 ,$698.25 ,$281.21 ,$457.87 ,$228.94 ,$686.81 ,$572.34 ,$610.50 ,$633.39
Hoopeston Regional Hlth Center,8980636,pegfilgrastim-jmdb 6 mg/0.6 mL subcutaneous syringe,67457083306,,636,"$14,663.92 ","$14,663.92 ","$4,105.90 ","$13,417.49 ","$10,264.74 ","$12,273.70 ","$13,417.49 ","$13,417.49 ","$13,417.49 ","$5,403.65 ","$8,798.35 ","$4,399.18 ","$13,197.53 ","$10,997.94 ","$11,731.14 ","$12,171.05 "
Hoopeston Regional Hlth Center,8980636,medroxyPROGESTERone 150 mg/mL intramuscular suspension,67457088701,J1050,636,$229.67 ,$229.67 ,$64.31 ,$210.15 ,$160.77 ,$192.23 ,$210.15 ,$210.15 ,$210.15 ,$84.63 ,$137.80 ,$68.90 ,$206.70 ,$172.25 ,$183.74 ,$190.63
Hoopeston Regional Hlth Center,8980636,dronabinoL 2.5 mg capsule,67877056860,Q0167,636,$31.11 ,$31.11 ,$8.71 ,$28.47 ,$21.78 ,$26.04 ,$28.47 ,$28.47 ,$28.47 ,$11.46 ,$18.67 ,$9.33 ,$28.00 ,$23.33 ,$24.89 ,$25.82
Hoopeston Regional Hlth Center,8980636,sirolimus 1 mg tablet,68084091525,J7520,636,$67.81 ,$67.81 ,$18.99 ,$62.05 ,$47.47 ,$56.76 ,$62.05 ,$62.05 ,$62.05 ,$24.99 ,$40.69 ,$20.34 ,$61.03 ,$50.86 ,$54.25 ,$56.28
Hoopeston Regional Hlth Center,8980636,ondansetron 4 mg disintegrating tablet,68462015713,Q0162,636,$89.05 ,$89.05 ,$24.93 ,$81.48 ,$62.34 ,$74.53 ,$81.48 ,$81.48 ,$81.48 ,$32.81 ,$53.43 ,$26.72 ,$80.15 ,$66.79 ,$71.24 ,$73.91
Hoopeston Regional Hlth Center,8980636,ondansetron 4 mg disintegrating tablet,68462015740,Q0162,636,$89.05 ,$89.05 ,$24.93 ,$81.48 ,$62.34 ,$74.53 ,$81.48 ,$81.48 ,$81.48 ,$32.81 ,$53.43 ,$26.72 ,$80.15 ,$66.79 ,$71.24 ,$73.91
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",68516521601,P9047,636,$324.66 ,$324.66 ,$90.90 ,$297.06 ,$227.26 ,$271.74 ,$297.06 ,$297.06 ,$297.06 ,$119.64 ,$194.80 ,$97.40 ,$292.19 ,$243.50 ,$259.73 ,$269.47
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",68516521603,P9047,636,$324.66 ,$324.66 ,$90.90 ,$297.06 ,$227.26 ,$271.74 ,$297.06 ,$297.06 ,$297.06 ,$119.64 ,$194.80 ,$97.40 ,$292.19 ,$243.50 ,$259.73 ,$269.47
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",68516521604,P9047,636,$324.66 ,$324.66 ,$90.90 ,$297.06 ,$227.26 ,$271.74 ,$297.06 ,$297.06 ,$297.06 ,$119.64 ,$194.80 ,$97.40 ,$292.19 ,$243.50 ,$259.73 ,$269.47
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",68516521605,P9046,636,$195.46 ,$195.46 ,$54.73 ,$178.85 ,$136.82 ,$163.60 ,$178.85 ,$178.85 ,$178.85 ,$72.03 ,$117.28 ,$58.64 ,$175.91 ,$146.60 ,$156.37 ,$162.23
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",68516521606,P9046,636,$195.46 ,$195.46 ,$54.73 ,$178.85 ,$136.82 ,$163.60 ,$178.85 ,$178.85 ,$178.85 ,$72.03 ,$117.28 ,$58.64 ,$175.91 ,$146.60 ,$156.37 ,$162.23
Hoopeston Regional Hlth Center,8980636,glatiramer 20 mg/mL subcutaneous syringe,68546031730,J1595,636,"$1,118.10 ","$1,118.10 ",$313.07 ,"$1,023.06 ",$782.67 ,$935.85 ,"$1,023.06 ","$1,023.06 ","$1,023.06 ",$412.02 ,$670.86 ,$335.43 ,"$1,006.29 ",$838.58 ,$894.48 ,$928.02
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",68982064301,P9047,636,$404.40 ,$404.40 ,$113.23 ,$370.03 ,$283.08 ,$338.48 ,$370.03 ,$370.03 ,$370.03 ,$149.02 ,$242.64 ,$121.32 ,$363.96 ,$303.30 ,$323.52 ,$335.65
Hoopeston Regional Hlth Center,8980636,"albumin, human 25 % intravenous solution",68982064302,P9047,636,$404.40 ,$404.40 ,$113.23 ,$370.03 ,$283.08 ,$338.48 ,$370.03 ,$370.03 ,$370.03 ,$149.02 ,$242.64 ,$121.32 ,$363.96 ,$303.30 ,$323.52 ,$335.65
Hoopeston Regional Hlth Center,8980636,dexAMETHasone sodium phosphate (PF) 10 mg/mL injection solution,70069002101,J1100,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,pegfilgrastim-cbqv 6 mg/0.6 mL subcutaneous syringe,70114010101,,636,"$14,663.92 ","$14,663.92 ","$4,105.90 ","$13,417.49 ","$10,264.74 ","$12,273.70 ","$13,417.49 ","$13,417.49 ","$13,417.49 ","$5,403.65 ","$8,798.35 ","$4,399.18 ","$13,197.53 ","$10,997.94 ","$11,731.14 ","$12,171.05 "
Hoopeston Regional Hlth Center,8980636,fluconazole 200 mg/100 mL in sod. chloride (iso) intravenous piggyback,70655000210,J1450,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,fluconazole 400 mg/200 mL in sod. chloride(iso) intravenous piggyback,70655008806,J1450,636,$52.29 ,$52.29 ,$14.64 ,$47.85 ,$36.60 ,$43.77 ,$47.85 ,$47.85 ,$47.85 ,$19.27 ,$31.37 ,$15.69 ,$47.06 ,$39.22 ,$41.83 ,$43.40
Hoopeston Regional Hlth Center,8980636,fomepizole 1 gram/mL intravenous solution,70710147801,J1451,636,"$8,452.07 ","$8,452.07 ","$2,366.58 ","$7,733.64 ","$5,916.45 ","$7,074.38 ","$7,733.64 ","$7,733.64 ","$7,733.64 ","$3,114.59 ","$5,071.24 ","$2,535.62 ","$7,606.86 ","$6,339.05 ","$6,761.66 ","$7,015.22 "
Hoopeston Regional Hlth Center,8980636,mycophenolate mofetil 250 mg capsule,70748018601,J7517,636,$20.61 ,$20.61 ,$5.77 ,$18.86 ,$14.43 ,$17.25 ,$18.86 ,$18.86 ,$18.86 ,$7.59 ,$12.37 ,$6.18 ,$18.55 ,$15.46 ,$16.49 ,$17.11
Hoopeston Regional Hlth Center,8980636,ketorolac 60 mg/2 mL intramuscular solution,70860070102,J1885,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,prochlorperazine Edisylate 10 mg/2 mL (5 mg/mL) injection solution,70860077802,J0780,636,$47.75 ,$47.75 ,$13.37 ,$43.69 ,$33.43 ,$39.97 ,$43.69 ,$43.69 ,$43.69 ,$17.60 ,$28.65 ,$14.33 ,$42.98 ,$35.81 ,$38.20 ,$39.63
Hoopeston Regional Hlth Center,8980636,"tagraxofusp-erzs 1,000 mcg/mL intravenous solution",72187040101,,636,"$78,645.71 ","$78,645.71 ","$22,020.80 ","$71,960.82 ","$55,052.00 ","$65,826.46 ","$71,960.82 ","$71,960.82 ","$71,960.82 ","$28,980.94 ","$47,187.43 ","$23,593.71 ","$70,781.14 ","$58,984.28 ","$62,916.57 ","$65,275.94 "
Hoopeston Regional Hlth Center,8980636,ketorolac 15 mg/mL injection solution,72611071901,J1885,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,phenylephrine 10 mg/mL injection solution,76014000410,J2370,636,$87.36 ,$87.36 ,$24.46 ,$79.93 ,$61.15 ,$73.12 ,$79.93 ,$79.93 ,$79.93 ,$32.19 ,$52.42 ,$26.21 ,$78.62 ,$65.52 ,$69.89 ,$72.51
Hoopeston Regional Hlth Center,8980636,morphine 4 mg/mL injection syringe,76045000510,J2270,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"HYDROmorphone 0.5 mg/0.5 mL injection syringe,HYDROmorphone (PF) 0.5 mg/0.5 mL injection syringe",76045000905,J1170,636,$44.27 ,$44.27 ,$12.40 ,$40.51 ,$30.99 ,$37.05 ,$40.51 ,$40.51 ,$40.51 ,$16.31 ,$26.56 ,$13.28 ,$39.84 ,$33.20 ,$35.42 ,$36.74
Hoopeston Regional Hlth Center,8980636,"phytonadione (vitamin K1) 1 mg/0.5 mL injection solution,phytonadione (vitamin K1) 1 mg/0.5 mL injection syringe",76329124001,,636,$175.62 ,$175.62 ,$49.17 ,$160.69 ,$122.93 ,$146.99 ,$160.69 ,$160.69 ,$160.69 ,$64.72 ,$105.37 ,$52.69 ,$158.06 ,$131.72 ,$140.50 ,$145.76
Hoopeston Regional Hlth Center,8980636,EPINEPHrine 0.1 mg/mL injection syringe,76329331601,J0171,636,$64.51 ,$64.51 ,$18.06 ,$59.03 ,$45.16 ,$53.99 ,$59.03 ,$59.03 ,$59.03 ,$23.77 ,$38.71 ,$19.35 ,$58.06 ,$48.38 ,$51.61 ,$53.54
Hoopeston Regional Hlth Center,8980636,naloxone 1 mg/mL injection syringe,76329336901,J2310,636,$118.64 ,$118.64 ,$33.22 ,$108.56 ,$83.05 ,$99.30 ,$108.56 ,$108.56 ,$108.56 ,$43.72 ,$71.18 ,$35.59 ,$106.78 ,$88.98 ,$94.91 ,$98.47
Hoopeston Regional Hlth Center,8980636,midazolam 1 mg/mL Injection,9999501298,J2250,636,$145.61 ,$145.61 ,$40.77 ,$133.23 ,$101.93 ,$121.88 ,$133.23 ,$133.23 ,$133.23 ,$53.66 ,$87.37 ,$43.68 ,$131.05 ,$109.21 ,$116.49 ,$120.86
Hoopeston Regional Hlth Center,8980637,apixaban 5 mg tablet,3089421,,637,$43.08 ,$43.08 ,$12.06 ,$39.42 ,$30.16 ,$36.06 ,$39.42 ,$39.42 ,$39.42 ,$15.87 ,$25.85 ,$12.92 ,$38.77 ,$32.31 ,$34.46 ,$35.76
Hoopeston Regional Hlth Center,8980637,montelukast 4 mg oral granules in packet,6384130,,637,$40.11 ,$40.11 ,$11.23 ,$36.70 ,$28.08 ,$33.57 ,$36.70 ,$36.70 ,$36.70 ,$14.78 ,$24.07 ,$12.03 ,$36.10 ,$30.08 ,$32.09 ,$33.29
Hoopeston Regional Hlth Center,8980637,riMANTAdine 100 mg tablet,115191101,,637,$17.47 ,$17.47 ,$4.89 ,$15.99 ,$12.23 ,$14.62 ,$15.99 ,$15.99 ,$15.99 ,$6.44 ,$10.48 ,$5.24 ,$15.72 ,$13.10 ,$13.98 ,$14.50
Hoopeston Regional Hlth Center,8980637,multivitamin with folic acid 400 mcg tablet,904053061,,637,$0.59 ,$0.59 ,$0.17 ,$0.54 ,$0.41 ,$0.49 ,$0.54 ,$0.54 ,$0.54 ,$0.22 ,$0.35 ,$0.18 ,$0.53 ,$0.44 ,$0.47 ,$0.49
Hoopeston Regional Hlth Center,8980637,HYDROcodone 10 mg-chlorpheniramine 8 mg/5 mL oral susp extend.rel 12hr,9999054867,,637,$23.43 ,$23.43 ,$6.56 ,$21.44 ,$16.40 ,$19.61 ,$21.44 ,$21.44 ,$21.44 ,$8.63 ,$14.06 ,$7.03 ,$21.09 ,$17.57 ,$18.74 ,$19.45
Hoopeston Regional Hlth Center,8980637,vancomycin 250 mg capsule,17478074202,,637,$210.33 ,$210.33 ,$58.89 ,$192.45 ,$147.23 ,$176.05 ,$192.45 ,$192.45 ,$192.45 ,$77.51 ,$126.20 ,$63.10 ,$189.30 ,$157.75 ,$168.26 ,$174.57
Hoopeston Regional Hlth Center,8980637,tiZANidine 2 mg tablet,60505025103,,637,$8.02 ,$8.02 ,$2.25 ,$7.34 ,$5.61 ,$6.71 ,$7.34 ,$7.34 ,$7.34 ,$2.96 ,$4.81 ,$2.41 ,$7.22 ,$6.02 ,$6.42 ,$6.66
Hoopeston Regional Hlth Center,8980637,alvimopan 12 mg capsule,67919002010,,637,$771.88 ,$771.88 ,$216.13 ,$706.27 ,$540.32 ,$646.06 ,$706.27 ,$706.27 ,$706.27 ,$284.44 ,$463.13 ,$231.56 ,$694.69 ,$578.91 ,$617.50 ,$640.66
Hoopeston Regional Hlth Center,9100220,RECOVERY PHASE I 1ST 15 MINS,,,710,"$1,040.00 ","$1,040.00 ",$291.20 ,$951.60 ,$728.00 ,$870.48 ,$951.60 ,$951.60 ,$951.60 ,$383.24 ,$624.00 ,$312.00 ,$936.00 ,$780.00 ,$832.00 ,$863.20
Hoopeston Regional Hlth Center,9100221,RECOVERY PHASE II 1ST HOUR,,,710,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,9100222,RECOVERY PHASE I EA ADD 15 MINS,,,710,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,9100223,RECOVERY PHASE I EA ADD 15 MINS,,,710,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,8493005,ELECTROCARDIOGRAM TRACING ONLY,,93005,730,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9650046,EKG W/ INTERPRETATION AND REPORT,,93000,730,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,9493005,ELECTROCARDIOGRAM TRACING ONLY,,93005,730,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9400404,ELECTROCARDIOGRAM TRACING ONLY AS PART OF IPPE,,G0404,730,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,8493225,CARDIAC HOLTER 24 HR MNTR RCRDNG,,93225,731,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,8293270,XTRNL PT ACTIV ECG TRANSMIS RECORDING 30 DAYS,,93270,731,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9493225,"EXT ECG RECORD CONTIN 48 HR, RECORD",,93225,731,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9493226,"EXT ECG RECORD CONTIN 48 HR, SCAN ANALYSIS W REPORT",,93226,731,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,8493226,"EXT ECG RECORD CONTIN 48 HR, SCAN ANALYSIS W REPORT",,93226,731,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,9027605,WOUND VAC DRESSING CHANGE,,97605,761,$540.00 ,$540.00 ,$151.20 ,$494.10 ,$378.00 ,$451.98 ,$494.10 ,$494.10 ,$494.10 ,$198.99 ,$324.00 ,$162.00 ,$486.00 ,$405.00 ,$432.00 ,$448.20
Hoopeston Regional Hlth Center,9800072,OUTPATIENT PROCEDURE NEW PATIENT,,99201,761,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,9336520,THERAPEUTIC APHERESIS,,,761,"$3,500.00 ","$3,500.00 ",$980.00 ,"$3,202.50 ","$2,450.00 ","$2,929.50 ","$3,202.50 ","$3,202.50 ","$3,202.50 ","$1,289.75 ","$2,100.00 ","$1,050.00 ","$3,150.00 ","$2,625.00 ","$2,800.00 ","$2,905.00 "
Hoopeston Regional Hlth Center,9097597,"SELECTIVE DEBRIDEMNT, 20SQ CM OR <",,,761,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,9010000,I&D INTEGUMENT,,,761,$420.00 ,$420.00 ,$117.60 ,$384.30 ,$294.00 ,$351.54 ,$384.30 ,$384.30 ,$384.30 ,$154.77 ,$252.00 ,$126.00 ,$378.00 ,$315.00 ,$336.00 ,$348.60
Hoopeston Regional Hlth Center,9449465,EVALUATN GI-OSTOMY TUBE,,49465,761,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,9432555,THORACENTESIS W/IMAGING,,32555,761,"$1,280.00 ","$1,280.00 ",$358.40 ,"$1,171.20 ",$896.00 ,"$1,071.36 ","$1,171.20 ","$1,171.20 ","$1,171.20 ",$471.68 ,$768.00 ,$384.00 ,"$1,152.00 ",$960.00 ,"$1,024.00 ","$1,062.40 "
Hoopeston Regional Hlth Center,9020010,SPINAL PUNCTURE,,,761,$710.00 ,$710.00 ,$198.80 ,$649.65 ,$497.00 ,$594.27 ,$649.65 ,$649.65 ,$649.65 ,$261.64 ,$426.00 ,$213.00 ,$639.00 ,$532.50 ,$568.00 ,$589.30
Hoopeston Regional Hlth Center,9436591,COLLECT BLOOD FROM IMPLANTED VENOUS ACCESS DEVICE,,36591,761,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,9410004,FINE NEEDLE ASPIRATION BX W/O IMG GDN EA ADDL,,10004,761,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,9410005,FINE NEEDLE ASPIRATION BX W/US GDN 1ST LSN,,10005,761,$310.00 ,$310.00 ,$86.80 ,$283.65 ,$217.00 ,$259.47 ,$283.65 ,$283.65 ,$283.65 ,$114.24 ,$186.00 ,$93.00 ,$279.00 ,$232.50 ,$248.00 ,$257.30
Hoopeston Regional Hlth Center,9410006,FINE NEEDLE ASPIRATION BX W/US GDN EA ADDL,,10006,761,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,9410007,FINE NEEDLE ASPIRATION BX W/FLUOR GDN 1ST LESION,,10007,761,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,9410008,FINE NEEDLE ASPIRATION BX W/FLUOR GDN EA ADDL,,10008,761,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,9410009,FINE NEEDLE ASPIRATION BX W/CT GDN 1ST LESION,,10009,761,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9410010,FINE NEEDLE ASPIRATION BX W/CT GDN EA ADDL,,10010,761,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9410011,FINE NEEDLE ASPIRATION BX W/MR GDN 1ST LESION,,10011,761,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,9410012,FINE NEEDLE ASPIRATION BX W/MR GDN EA ADDL,,10012,761,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,9427369,NJX PX CNTRST KNE ARTHG CNTRST ENHNCD CT/MRI KNE,,27369,761,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,9436572,INSERTION PICC W/RS&I < 5 YR,,36572,761,"$1,160.00 ","$1,160.00 ",$324.80 ,"$1,061.40 ",$812.00 ,$970.92 ,"$1,061.40 ","$1,061.40 ","$1,061.40 ",$427.46 ,$696.00 ,$348.00 ,"$1,044.00 ",$870.00 ,$928.00 ,$962.80
Hoopeston Regional Hlth Center,9436573,INSERTION PICC W/RS&I 5 YR/>,,36573,761,"$2,040.00 ","$2,040.00 ",$571.20 ,"$1,866.60 ","$1,428.00 ","$1,707.48 ","$1,866.60 ","$1,866.60 ","$1,866.60 ",$751.74 ,"$1,224.00 ",$612.00 ,"$1,836.00 ","$1,530.00 ","$1,632.00 ","$1,693.20 "
Hoopeston Regional Hlth Center,9443762,PERQ REPLACEMENT GTUBE NOT REQ REVJ GSTRST TRC,,43762,761,$910.00 ,$910.00 ,$254.80 ,$832.65 ,$637.00 ,$761.67 ,$832.65 ,$832.65 ,$832.65 ,$335.34 ,$546.00 ,$273.00 ,$819.00 ,$682.50 ,$728.00 ,$755.30
Hoopeston Regional Hlth Center,9443763,PERQ REPLACEMENT GTUBE REQ REVJ GSTRST TRC,,43763,761,$990.00 ,$990.00 ,$277.20 ,$905.85 ,$693.00 ,$828.63 ,$905.85 ,$905.85 ,$905.85 ,$364.82 ,$594.00 ,$297.00 ,$891.00 ,$742.50 ,$792.00 ,$821.70
Hoopeston Regional Hlth Center,9450436,PERQ DILATION XST TRC ENDOUROLOGIC PX W/IMG,,50436,761,"$4,550.00 ","$4,550.00 ","$1,274.00 ","$4,163.25 ","$3,185.00 ","$3,808.35 ","$4,163.25 ","$4,163.25 ","$4,163.25 ","$1,676.68 ","$2,730.00 ","$1,365.00 ","$4,095.00 ","$3,412.50 ","$3,640.00 ","$3,776.50 "
Hoopeston Regional Hlth Center,9450437,PERQ DILATION XST TRC NEW ACCESS RENAL COLTJ SYS,,50437,761,"$7,660.00 ","$7,660.00 ","$2,144.80 ","$7,008.90 ","$5,362.00 ","$6,411.42 ","$7,008.90 ","$7,008.90 ","$7,008.90 ","$2,822.71 ","$4,596.00 ","$2,298.00 ","$6,894.00 ","$5,745.00 ","$6,128.00 ","$6,357.80 "
Hoopeston Regional Hlth Center,9453854,TRURL DSTRJ PRST8 TISS RF WV THERMOTHERAPY,,53854,761,"$3,480.00 ","$3,480.00 ",$974.40 ,"$3,184.20 ","$2,436.00 ","$2,912.76 ","$3,184.20 ","$3,184.20 ","$3,184.20 ","$1,282.38 ","$2,088.00 ","$1,044.00 ","$3,132.00 ","$2,610.00 ","$2,784.00 ","$2,888.40 "
Hoopeston Regional Hlth Center,9026592,COLLCTN BLD SPCMN FROM PICC,,36592,761,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,9433016,PERICARDIOCENTESIS W/IMG GUIDANCE WHEN PERFORMED,,33016,761,"$2,810.00 ","$2,810.00 ",$786.80 ,"$2,571.15 ","$1,967.00 ","$2,351.97 ","$2,571.15 ","$2,571.15 ","$2,571.15 ","$1,035.49 ","$1,686.00 ",$843.00 ,"$2,529.00 ","$2,107.50 ","$2,248.00 ","$2,332.30 "
Hoopeston Regional Hlth Center,9462328,DIAGNOSTIC LUMBAR SPINAL PUNCTURE W/FLUOR OR CT,,62328,761,"$2,150.00 ","$2,150.00 ",$602.00 ,"$1,967.25 ","$1,505.00 ","$1,799.55 ","$1,967.25 ","$1,967.25 ","$1,967.25 ",$792.28 ,"$1,290.00 ",$645.00 ,"$1,935.00 ","$1,612.50 ","$1,720.00 ","$1,784.50 "
Hoopeston Regional Hlth Center,9462329,THERAPEUTIC SPINAL PNXR DRAINAGE CSF W/FLUOR/CT,,62329,761,"$2,690.00 ","$2,690.00 ",$753.20 ,"$2,461.35 ","$1,883.00 ","$2,251.53 ","$2,461.35 ","$2,461.35 ","$2,461.35 ",$991.27 ,"$1,614.00 ",$807.00 ,"$2,421.00 ","$2,017.50 ","$2,152.00 ","$2,232.70 "
Hoopeston Regional Hlth Center,9464451,INJECTION AA&/STRD NERVES NRVTG SI JOINT W/IMG,,64451,761,"$2,950.00 ","$2,950.00 ",$826.00 ,"$2,699.25 ","$2,065.00 ","$2,469.15 ","$2,699.25 ","$2,699.25 ","$2,699.25 ","$1,087.08 ","$1,770.00 ",$885.00 ,"$2,655.00 ","$2,212.50 ","$2,360.00 ","$2,448.50 "
Hoopeston Regional Hlth Center,9464454,INJECTION AA&/STRD GENICULAR NRV BRANCHES W/IMG,,64454,761,"$3,050.00 ","$3,050.00 ",$854.00 ,"$2,790.75 ","$2,135.00 ","$2,552.85 ","$2,790.75 ","$2,790.75 ","$2,790.75 ","$1,123.93 ","$1,830.00 ",$915.00 ,"$2,745.00 ","$2,287.50 ","$2,440.00 ","$2,531.50 "
Hoopeston Regional Hlth Center,9464624,DESTRUCTION NEUROLYTIC AGT GENICULAR NERVE W/IMG,,64624,761,"$4,440.00 ","$4,440.00 ","$1,243.20 ","$4,062.60 ","$3,108.00 ","$3,716.28 ","$4,062.60 ","$4,062.60 ","$4,062.60 ","$1,636.14 ","$2,664.00 ","$1,332.00 ","$3,996.00 ","$3,330.00 ","$3,552.00 ","$3,685.20 "
Hoopeston Regional Hlth Center,9464625,RADIOFREQUENCY ABLTJ NRV NRVTG SI JT W/IMG GDN,,64625,761,"$5,760.00 ","$5,760.00 ","$1,612.80 ","$5,270.40 ","$4,032.00 ","$4,821.12 ","$5,270.40 ","$5,270.40 ","$5,270.40 ","$2,122.56 ","$3,456.00 ","$1,728.00 ","$5,184.00 ","$4,320.00 ","$4,608.00 ","$4,780.80 "
Hoopeston Regional Hlth Center,8009803,HOSPITAL OUTPT CLINIC VISIT SPECIMEN COLLECTION,,C9803,761,$60.00 ,$60.00 ,$16.80 ,$54.90 ,$42.00 ,$50.22 ,$54.90 ,$54.90 ,$54.90 ,$22.11 ,$36.00 ,$18.00 ,$54.00 ,$45.00 ,$48.00 ,$49.80
Hoopeston Regional Hlth Center,9432408,CORE NEEDLE BX LUNG/MEDIASTINUM PERQ W/IMG,,32408,761,"$2,880.00 ","$2,880.00 ",$806.40 ,"$2,635.20 ","$2,016.00 ","$2,410.56 ","$2,635.20 ","$2,635.20 ","$2,635.20 ","$1,061.28 ","$1,728.00 ",$864.00 ,"$2,592.00 ","$2,160.00 ","$2,304.00 ","$2,390.40 "
Hoopeston Regional Hlth Center,9455880,TRANSRECTAL ABLTJ MAL PRST8 TISSUE HIFU W/US,,55880,761,"$4,630.00 ","$4,630.00 ","$1,296.40 ","$4,236.45 ","$3,241.00 ","$3,875.31 ","$4,236.45 ","$4,236.45 ","$4,236.45 ","$1,706.16 ","$2,778.00 ","$1,389.00 ","$4,167.00 ","$3,472.50 ","$3,704.00 ","$3,842.90 "
Hoopeston Regional Hlth Center,9403001,"INSRTN NON-TUNNELED CENTRAL CATH, PT < 5 YRS",,36555,761,"$1,250.00 ","$1,250.00 ",$350.00 ,"$1,143.75 ",$875.00 ,"$1,046.25 ","$1,143.75 ","$1,143.75 ","$1,143.75 ",$460.63 ,$750.00 ,$375.00 ,"$1,125.00 ",$937.50 ,"$1,000.00 ","$1,037.50 "
Hoopeston Regional Hlth Center,9403002,"INSRTN NON-TUNNELED CENTRAL CATH, PT 5 YRS OR >",,36556,761,"$1,340.00 ","$1,340.00 ",$375.20 ,"$1,226.10 ",$938.00 ,"$1,121.58 ","$1,226.10 ","$1,226.10 ","$1,226.10 ",$493.79 ,$804.00 ,$402.00 ,"$1,206.00 ","$1,005.00 ","$1,072.00 ","$1,112.20 "
Hoopeston Regional Hlth Center,9403003,"INSRTN PICC W/O SUBQ PORT/PUMP, PT < 5 YRS",,36568,761,"$1,070.00 ","$1,070.00 ",$299.60 ,$979.05 ,$749.00 ,$895.59 ,$979.05 ,$979.05 ,$979.05 ,$394.30 ,$642.00 ,$321.00 ,$963.00 ,$802.50 ,$856.00 ,$888.10
Hoopeston Regional Hlth Center,9403004,"INSRTN PICC W/O SUBQ PORT/PUMP, PT 5 YRS OR >",,36569,761,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,9890471,VACCINE ADMINISTRATION,,90471,771,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9890472,VACCINE ADMIN EACH ADDITIONAL,,90472,771,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9810008,VACCINE ADMIN - FLU,,90471,771,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9810009,VACCINE ADMIN - PNEUMONIA,,90471,771,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9020471,VACCINE ADMINISTRATION,,90471,771,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9020472,VACCINE ADMIN EACH ADDITIONAL,,90472,771,$94.00 ,$94.00 ,$26.32 ,$86.01 ,$65.80 ,$78.68 ,$86.01 ,$86.01 ,$86.01 ,$34.64 ,$56.40 ,$28.20 ,$84.60 ,$70.50 ,$75.20 ,$78.02
Hoopeston Regional Hlth Center,9020008,VACCINE ADMIN - FLU,,90471,771,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9020009,VACCINE ADMIN - PNEUMONIA,,90471,771,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,9290471,HRHC FLU CLINIC ADMIN,,90471,771,$22.00 ,$22.00 ,$6.16 ,$20.13 ,$15.40 ,$18.41 ,$20.13 ,$20.13 ,$20.13 ,$8.11 ,$13.20 ,$6.60 ,$19.80 ,$16.50 ,$17.60 ,$18.26
Hoopeston Regional Hlth Center,9000010,VACCINE ADMIN - HEPATITIS B,,90471,771,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,8020239,BAMLANIVIMAB-XXXX INFUSION,,M0239,771,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,96127,BEHAV ASSMT W/SCORE & DOCD/STAND INSTRUMENT,,96127,900,$30.00 ,$30.00 ,$8.40 ,$27.45 ,$21.00 ,$25.11 ,$27.45 ,$27.45 ,$27.45 ,$11.06 ,$18.00 ,$9.00 ,$27.00 ,$22.50 ,$24.00 ,$24.90
Hoopeston Regional Hlth Center,90785,MEDICAL SERVICE,,90785,900,$28.00 ,$28.00 ,$7.84 ,$25.62 ,$19.60 ,$23.44 ,$25.62 ,$25.62 ,$25.62 ,$10.32 ,$16.80 ,$8.40 ,$25.20 ,$21.00 ,$22.40 ,$23.24
Hoopeston Regional Hlth Center,90791,MEDICAL SERVICE,,90791,900,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,90792,MEDICAL SERVICE,,90792,900,$520.00 ,$520.00 ,$145.60 ,$475.80 ,$364.00 ,$435.24 ,$475.80 ,$475.80 ,$475.80 ,$191.62 ,$312.00 ,$156.00 ,$468.00 ,$390.00 ,$416.00 ,$431.60
Hoopeston Regional Hlth Center,90832,MEDICAL SERVICE,,90832,900,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,90834,MEDICAL SERVICE,,90834,900,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,90837,MEDICAL SERVICE,,90837,900,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,90839,MEDICAL SERVICE,,90839,900,$400.00 ,$400.00 ,$112.00 ,$366.00 ,$280.00 ,$334.80 ,$366.00 ,$366.00 ,$366.00 ,$147.40 ,$240.00 ,$120.00 ,$360.00 ,$300.00 ,$320.00 ,$332.00
Hoopeston Regional Hlth Center,90840,MEDICAL SERVICE,,90840,900,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,90853,MEDICAL SERVICE,,90853,915,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,90846,MEDICAL SERVICE,,90846,916,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,90847,MEDICAL SERVICE,,90847,916,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,96112,DEVELOPMENTAL TST ADMIN PHYS/QHP 1ST HOUR,,96112,918,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,96113,DEVELOPMENTAL TST ADMIN PHYS/QHP EA ADDL 30 MIN,,96113,918,$220.00 ,$220.00 ,$61.60 ,$201.30 ,$154.00 ,$184.14 ,$201.30 ,$201.30 ,$201.30 ,$81.07 ,$132.00 ,$66.00 ,$198.00 ,$165.00 ,$176.00 ,$182.60
Hoopeston Regional Hlth Center,96121,NEUROBEHAVIORAL STATUS XM PHYS/QHP EA ADDL HOUR,,96121,918,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,96130,PSYCHOLOGICAL TST EVAL SVC PHYS/QHP FIRST HOUR,,96130,918,"$1,460.00 ","$1,460.00 ",$408.80 ,"$1,335.90 ","$1,022.00 ","$1,222.02 ","$1,335.90 ","$1,335.90 ","$1,335.90 ",$538.01 ,$876.00 ,$438.00 ,"$1,314.00 ","$1,095.00 ","$1,168.00 ","$1,211.80 "
Hoopeston Regional Hlth Center,96131,PSYCHOLOGICAL TST EVAL SVC PHYS/QHP EA ADDL HOUR,,96131,918,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,96132,NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP 1ST HOUR,,96132,918,"$1,460.00 ","$1,460.00 ",$408.80 ,"$1,335.90 ","$1,022.00 ","$1,222.02 ","$1,335.90 ","$1,335.90 ","$1,335.90 ",$538.01 ,$876.00 ,$438.00 ,"$1,314.00 ","$1,095.00 ","$1,168.00 ","$1,211.80 "
Hoopeston Regional Hlth Center,96133,NEUROPSYCHOLOGICAL TST EVAL PHYS/QHP EA ADDL HR,,96133,918,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,96136,PSYL/NRPSYCL TST PHYS/QHP 2+ TST 1ST 30 MIN,,96136,918,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,96137,PSYCL/NRPSYCL TST PHYS/QHP 2+ TST EA ADDL 30 MIN,,96137,918,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,96138,PSYCL/NRPSYCL TST TECH 2+ TST 1ST 30 MIN,,96138,918,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,96139,PSYCL/NRPSYCL TST TECH 2+ TST EA ADDL 30 MIN,,96139,918,$125.00 ,$125.00 ,$35.00 ,$114.38 ,$87.50 ,$104.63 ,$114.38 ,$114.38 ,$114.38 ,$46.06 ,$75.00 ,$37.50 ,$112.50 ,$93.75 ,$100.00 ,$103.75
Hoopeston Regional Hlth Center,96146,PSYCL/NRPSYCL TST ELEC PLATFORM AUTO RESULT,,96146,918,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,96110,DEVELOPMENTAL SCREEN W/SCORING & DOC STD INSTRM,,96110,918,$32.00 ,$32.00 ,$8.96 ,$29.28 ,$22.40 ,$26.78 ,$29.28 ,$29.28 ,$29.28 ,$11.79 ,$19.20 ,$9.60 ,$28.80 ,$24.00 ,$25.60 ,$26.56
Hoopeston Regional Hlth Center,96116,MEDICAL SERVICE,,96116,918,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,96160,PT-FOCUSED HLTH RISK ASSMT SCORE DOC STND INSTRM,,96160,918,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,96161,CAREGIVER HLTH RISK ASSMT SCORE DOC STND INSTRM,,96161,918,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,95250,CONT GLUC MNTR PHYSICIAN/QHP PROVIDED EQUIPMENT,,95250,920,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,99173,"VISUAL SCREENING TEST, BILAT",,99173,920,$48.00 ,$48.00 ,$13.44 ,$43.92 ,$33.60 ,$40.18 ,$43.92 ,$43.92 ,$43.92 ,$17.69 ,$28.80 ,$14.40 ,$43.20 ,$36.00 ,$38.40 ,$39.84
Hoopeston Regional Hlth Center,95251,CONTINUOUS GLUCOSE MONITORING ANALYSIS I&R,,95251,920,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,8493880,DUPLEX SCN EXTRCRN ART BILAT CMPLT,,93880,921,"$1,260.00 ","$1,260.00 ",$352.80 ,"$1,152.90 ",$882.00 ,"$1,054.62 ","$1,152.90 ","$1,152.90 ","$1,152.90 ",$464.31 ,$756.00 ,$378.00 ,"$1,134.00 ",$945.00 ,"$1,008.00 ","$1,045.80 "
Hoopeston Regional Hlth Center,8493922,ARTL EXTMTY DPPLR SNGL LVL BILAT,,93922,921,$440.00 ,$440.00 ,$123.20 ,$402.60 ,$308.00 ,$368.28 ,$402.60 ,$402.60 ,$402.60 ,$162.14 ,$264.00 ,$132.00 ,$396.00 ,$330.00 ,$352.00 ,$365.20
Hoopeston Regional Hlth Center,8493923,ARTL EXTMTY DPPLR MULT LVLS BILAT,,93923,921,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,8493925,DPLX SCN LWR EXT ART BILAT CMPLT,,93925,921,$890.00 ,$890.00 ,$249.20 ,$814.35 ,$623.00 ,$744.93 ,$814.35 ,$814.35 ,$814.35 ,$327.97 ,$534.00 ,$267.00 ,$801.00 ,$667.50 ,$712.00 ,$738.70
Hoopeston Regional Hlth Center,8493926,DPLX SCN LWR EXT ART UNILT/LMTD,,93926,921,$550.00 ,$550.00 ,$154.00 ,$503.25 ,$385.00 ,$460.35 ,$503.25 ,$503.25 ,$503.25 ,$202.68 ,$330.00 ,$165.00 ,$495.00 ,$412.50 ,$440.00 ,$456.50
Hoopeston Regional Hlth Center,8493930,DPLX SCN UPPR EXT ART BILAT CMPLT,,93930,921,$640.00 ,$640.00 ,$179.20 ,$585.60 ,$448.00 ,$535.68 ,$585.60 ,$585.60 ,$585.60 ,$235.84 ,$384.00 ,$192.00 ,$576.00 ,$480.00 ,$512.00 ,$531.20
Hoopeston Regional Hlth Center,8493931,DPLX SCN UPPR EXT ART UNILT/LMTD,,93931,921,$400.00 ,$400.00 ,$112.00 ,$366.00 ,$280.00 ,$334.80 ,$366.00 ,$366.00 ,$366.00 ,$147.40 ,$240.00 ,$120.00 ,$360.00 ,$300.00 ,$320.00 ,$332.00
Hoopeston Regional Hlth Center,8493970,BILATERAL VENOUS DUPLEX,,93970,921,"$1,070.00 ","$1,070.00 ",$299.60 ,$979.05 ,$749.00 ,$895.59 ,$979.05 ,$979.05 ,$979.05 ,$394.30 ,$642.00 ,$321.00 ,$963.00 ,$802.50 ,$856.00 ,$888.10
Hoopeston Regional Hlth Center,8493971,FOLLOW-UP LMTD VEN DUPLEX,,93971,921,$720.00 ,$720.00 ,$201.60 ,$658.80 ,$504.00 ,$602.64 ,$658.80 ,$658.80 ,$658.80 ,$265.32 ,$432.00 ,$216.00 ,$648.00 ,$540.00 ,$576.00 ,$597.60
Hoopeston Regional Hlth Center,8493975,DPLX SCN ABD/PLVC/RTROPTNL CMPLT,,93975,921,"$1,210.00 ","$1,210.00 ",$338.80 ,"$1,107.15 ",$847.00 ,"$1,012.77 ","$1,107.15 ","$1,107.15 ","$1,107.15 ",$445.89 ,$726.00 ,$363.00 ,"$1,089.00 ",$907.50 ,$968.00 ,"$1,004.30 "
Hoopeston Regional Hlth Center,8493976,DPLX SCN ABD/PLVC/RTROPTNL LMTD,,93976,921,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,8493978,DPLX SCN ARTA/IVC/ILAC CMPLT,,93978,921,"$1,020.00 ","$1,020.00 ",$285.60 ,$933.30 ,$714.00 ,$853.74 ,$933.30 ,$933.30 ,$933.30 ,$375.87 ,$612.00 ,$306.00 ,$918.00 ,$765.00 ,$816.00 ,$846.60
Hoopeston Regional Hlth Center,9493880,US CAROTID DOPPLER BILATERAL,,93880,921,"$1,290.00 ","$1,290.00 ",$361.20 ,"$1,180.35 ",$903.00 ,"$1,079.73 ","$1,180.35 ","$1,180.35 ","$1,180.35 ",$475.37 ,$774.00 ,$387.00 ,"$1,161.00 ",$967.50 ,"$1,032.00 ","$1,070.70 "
Hoopeston Regional Hlth Center,9493922,US ABI,,93922,921,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,9493923,US SEGMENTAL PRESSURE,,93923,921,$670.00 ,$670.00 ,$187.60 ,$613.05 ,$469.00 ,$560.79 ,$613.05 ,$613.05 ,$613.05 ,$246.90 ,$402.00 ,$201.00 ,$603.00 ,$502.50 ,$536.00 ,$556.10
Hoopeston Regional Hlth Center,9493925,US LOWER EXTREMITY ARTERIAL BILATERAL,,93925,921,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,9493926,US LOWER EXT ARTERIAL,,93926,921,$670.00 ,$670.00 ,$187.60 ,$613.05 ,$469.00 ,$560.79 ,$613.05 ,$613.05 ,$613.05 ,$246.90 ,$402.00 ,$201.00 ,$603.00 ,$502.50 ,$536.00 ,$556.10
Hoopeston Regional Hlth Center,9493930,US UPPER EXTREMITY ARTERIAL BILATERAL,,93930,921,$660.00 ,$660.00 ,$184.80 ,$603.90 ,$462.00 ,$552.42 ,$603.90 ,$603.90 ,$603.90 ,$243.21 ,$396.00 ,$198.00 ,$594.00 ,$495.00 ,$528.00 ,$547.80
Hoopeston Regional Hlth Center,9493931,US UPPER EXTREMITY ARTERIAL,,93931,921,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,9493970,US UPPER/LOWER EXTREMITY VENOUS BILAT,,93970,921,"$1,300.00 ","$1,300.00 ",$364.00 ,"$1,189.50 ",$910.00 ,"$1,088.10 ","$1,189.50 ","$1,189.50 ","$1,189.50 ",$479.05 ,$780.00 ,$390.00 ,"$1,170.00 ",$975.00 ,"$1,040.00 ","$1,079.00 "
Hoopeston Regional Hlth Center,9493971,US EXTREMITY VENOUS,,93971,921,$890.00 ,$890.00 ,$249.20 ,$814.35 ,$623.00 ,$744.93 ,$814.35 ,$814.35 ,$814.35 ,$327.97 ,$534.00 ,$267.00 ,$801.00 ,$667.50 ,$712.00 ,$738.70
Hoopeston Regional Hlth Center,9493976,US RENAL ARTERY,,93976,921,"$1,100.00 ","$1,100.00 ",$308.00 ,"$1,006.50 ",$770.00 ,$920.70 ,"$1,006.50 ","$1,006.50 ","$1,006.50 ",$405.35 ,$660.00 ,$330.00 ,$990.00 ,$825.00 ,$880.00 ,$913.00
Hoopeston Regional Hlth Center,9493979,US AORTA DOPPLER,,93979,921,$960.00 ,$960.00 ,$268.80 ,$878.40 ,$672.00 ,$803.52 ,$878.40 ,$878.40 ,$878.40 ,$353.76 ,$576.00 ,$288.00 ,$864.00 ,$720.00 ,$768.00 ,$796.80
Hoopeston Regional Hlth Center,8493979,DPLX SCN ARTA/IVC/ILAC LMTD,,93979,921,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,9493975,DPLX SCN ABD/PLVC/RTROPTNL CMPLT,,93975,921,"$1,290.00 ","$1,290.00 ",$361.20 ,"$1,180.35 ",$903.00 ,"$1,079.73 ","$1,180.35 ","$1,180.35 ","$1,180.35 ",$475.37 ,$774.00 ,$387.00 ,"$1,161.00 ",$967.50 ,"$1,032.00 ","$1,070.70 "
Hoopeston Regional Hlth Center,95004,PERCUTANEOUS TESTS W/ALLERGENIC EXTRACTS,,95004,924,$23.00 ,$23.00 ,$6.44 ,$21.05 ,$16.10 ,$19.25 ,$21.05 ,$21.05 ,$21.05 ,$8.48 ,$13.80 ,$6.90 ,$20.70 ,$17.25 ,$18.40 ,$19.09
Hoopeston Regional Hlth Center,95024,INTRACUTANEOUS TESTS W/ALLERGENIC EXTRACTS,,95024,924,$29.00 ,$29.00 ,$8.12 ,$26.54 ,$20.30 ,$24.27 ,$26.54 ,$26.54 ,$26.54 ,$10.69 ,$17.40 ,$8.70 ,$26.10 ,$21.75 ,$23.20 ,$24.07
Hoopeston Regional Hlth Center,9800074,IM INJECTION OUTPT,,96372,940,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,9800075,IV PUSH ADMINISTRATION-OUT PT,,96374,940,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9800076,IV PUSH ADDITIONAL NEW DRUG OUT PT,,96375,940,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,9403009,CENTRAL LINE DRESSING CHANGE,,99211,940,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,9403010,DECLOTTING CENTRAL LINE,,,940,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,9403011,ACCESSING IMPLANTED PORT,,96523,940,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,8299195,PHLEBOTOMY,,99195,940,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,99195,PHLEBOTOMY,,99195,940,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,G0108,Diab manage trn per indiv,,G0108,942,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,G0109,Diab manage trn ind/group,,G0109,942,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,G0270,MNT subs tx for change dx,,G0270,942,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,G0271,Group MNT 2 or more 30 mins,,G0271,942,$63.00 ,$63.00 ,$17.64 ,$57.65 ,$44.10 ,$52.73 ,$57.65 ,$57.65 ,$57.65 ,$23.22 ,$37.80 ,$18.90 ,$56.70 ,$47.25 ,$50.40 ,$52.29
Hoopeston Regional Hlth Center,94010,BREATHING CAPACITY TEST,,94010,960,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,94060,EVAL OF BRONCHOSPASM,,94060,960,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,870,"ANESTH,BLADDER STONE SURG",,870,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,873,"ANESTH,KID STONE DESTRUCT",,873,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,880,"ANESTH,MAJOR LOW ABD VESSEL SURG",,880,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,882,"ANESTH,INFER VENA CAVAL LIGATION",,882,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,902,"ANESTH,ANORECTAL SURGERY",,902,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,904,"ANESTH,RADICAL PERINEAL SURGERY",,904,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,906,"ANESTH,REMOVAL OF VULVA",,906,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,908,"ANESTH,PERINEAL REMV OF PROSTATE",,908,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,910,"ANESTH,TRANSURETHRAL SURG,NOS",,910,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,912,"ANESTH,XURETHRAL BLADDER TUMOR SURG",,912,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,144,"ANESTH,CORNEAL TRANSPLANT",,144,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,914,"ANESTH,XURETHRAL REMOVAL OF PROSTATE",,914,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,916,"ANESTH,POST XURETHRAL BLEEDING CONTR",,916,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,918,"ANESTH,STONE RMVOVAL",,918,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,920,"ANESTH,MALE GENITALIA SURGERY",,920,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,922,"ANESTH,SPERM DUCT SURGERY",,922,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,924,"ANESTH,TESTIS EXPLORATION",,924,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,926,"ANESTH,RADICAL REMV TESTIS,INGUINAL",,926,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,928,"ANESTH,RADICAL REMV TESTIS,ABDOMINAL",,928,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,930,"ANESTH,TESTIS SUSPENSION",,930,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,932,"ANESTH,AMPUTATION OF PENIS",,932,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,145,"ANESTH, VITREORETINAL SURG",,145,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,934,"ANESTH,PENIS,NODES REMOVAL",,934,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,936,"ANESTH,PENIS,COMBO NODES REMOVAL",,936,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,938,"ANESTH,INSERT PENIS PROSTHESIS",,938,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,940,"ANESTH,VAGINAL PROCEDURES",,940,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,942,"ANESTH,COLPOT,VAGINECT,COLPORR,URETH PRO",,942,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,944,"ANESTH,VAGINAL HYSTERECTOMY",,944,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,948,"ANESTH,REPAIR OF CERVIX",,948,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,950,"ANESTH,VAGINAL ENDOSCOPY",,950,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,952,"ANESTH,HYSTEROSCOPY/VAG BX",,952,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1120,"ANESTH,BONY PELVIS SURGERY",,1120,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,147,"ANESTH,IRIDECTOMY",,147,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1130,"ANESTH,BODY CAST PROCEDURE",,1130,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1140,"ANESTH,AMPUTATION AT PELVIS",,1140,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1150,"ANESTH,RADICAL PELVIC TUMOR SURGERY",,1150,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1160,"ANESTH,PUBIS,SACROILIAC OPEN PROC",,1160,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1170,"ANESTH,PUBIS,SACROILIAC CLOSED PROC",,1170,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1200,"ANESTH,HIP JOINT PROCEDURE",,1200,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1202,"ANESTH,ARTHROSCOPY OF HIP",,1202,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1210,"ANESTH,HIP JOINT SURGERY",,1210,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,148,"ANESTH,EYE EXAM",,148,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1212,"ANESTH,HIP DISARTICULATION",,1212,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1214,"ANESTH,TOTAL HIP ARTHROPLASTY",,1214,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1220,"ANESTH,CLOSED PROC UPPER 2/3 FEMUR",,1220,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1230,"ANESTH,OPEN PROC UPPER 2/3 FEMUR",,1230,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1232,"ANESTH,AMPUTATION OF FEMUR",,1232,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1234,"ANESTH,RADICAL FEMUR SURG",,1234,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1250,"ANESTH,UPPER LEG SURGERY",,1250,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1260,"ANESTH,UPPER LEG VEINS SURG",,1260,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1270,"ANESTH,THIGH ARTERIES SURG",,1270,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1272,"ANESTH,FEMORAL ARTERY LIGATION",,1272,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,160,"ANESTH,NOSE,SINUS SURGERY",,160,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1274,"ANESTH,FEMORAL EMBOLECTOMY",,1274,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1320,"ANESTH,KNEE AREA SURGERY",,1320,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1340,"ANESTH,LOWER 1/3 FEMUR,CLOSED PROC",,1340,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1360,"ANESTH,LOWER 1/3 FEMUR,OPEN PROC",,1360,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1380,"ANESTH,KNEE JOINT,CLOSED PROCEDURE",,1380,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1382,"ANESTH,DX ARTHROSCOPIC PROC KNEE JOINT",,1382,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1390,"ANESTH,UPPER LEG,CLOSED PROCEDURE",,1390,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1392,"ANESTH,UPPER LEG,OPEN PROCEDURE",,1392,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1400,"ANESTH,KNEE JOINT; NOS",,1400,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1402,"ANESTH,TOTAL KNEE ARTHROPLASTY",,1402,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,162,"ANESTH,NOSE,RADICAL SINUS SURGERY",,162,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1404,"ANESTH,AMPUTATION AT KNEE",,1404,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1420,"ANESTH,KNEE JOINT CASTING",,1420,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1430,"ANESTH,KNEE VEINS SURGERY",,1430,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1432,"ANESTH,KNEE AV FISTULA VESSEL SURG",,1432,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1440,"ANESTH,KNEE ARTERIES SURG",,1440,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1442,"ANESTH,POPLIT THROMBOENDARTECTOMY",,1442,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1444,"ANESTH,POPLIT ARTERY EXCISION",,1444,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1462,"ANESTH,LOWER LEG,CLOSED PROCEDURE",,1462,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1464,"ANESTH,ARTHROSCOP PROC,ANKLE &/OR FOOT",,1464,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1470,"ANESTH,LOWER LEG,OPEN SURGERY",,1470,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,164,"ANESTH,BIOPSY OF NOSE",,164,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1472,"ANESTH,ACHILLES TENDON SURG",,1472,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1474,"ANESTH,GASTROCNEMIUS SURGERY",,1474,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1480,"ANESTH,LOWER LEG BONE SURG",,1480,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1482,"ANESTH,RADICAL LEG RESECTION",,1482,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1484,"ANESTH,LOWER LEG BONE REVISION",,1484,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1486,"ANESTH,ANKLE REPLACEMENT",,1486,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1490,"ANESTH,LOWER LEG CASTING",,1490,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1500,"ANESTH,LOWER LEG ARTERIES SURG",,1500,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1502,"ANESTH,LOWER LEG EMBOLECTOMY",,1502,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1520,"ANESTH,LOWER LEG VEIN SURG,NOS",,1520,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,170,"ANESTH,PROCEDURE ON MOUTH",,170,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1522,"ANESTH,LOWER LEG VEIN THROMBECTOMY",,1522,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1610,"ANESTH,SURGERY OF SHOULDER",,1610,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1620,"ANESTH,SHOULDER,CLOSED PROCEDURE",,1620,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1622,"ANESTH,DX ARTHROSC PROC,SHOULDER JOINT",,1622,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1630,"ANESTH,SHOULDER JOINT,NOS",,1630,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1634,"ANESTH,SHOULDER JOINT AMPUT",,1634,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1636,"ANESTH,FOREQUARTER AMPUT",,1636,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1638,"ANESTH,SHOULDER REPLACEMENT",,1638,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1650,"ANESTH,SHOULDER ARTERY SURG,NOS",,1650,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1652,"ANESTH,AXILLARY-BRACHIAL ANEURYSM",,1652,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,172,"ANESTH,CLEFT PALATE REPAIR",,172,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1654,"ANESTH,SHLDR VESSEL SURG,BYPASS GRFT",,1654,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1656,"ANESTH,AXILL-FEM BYPASS GRFT SURG",,1656,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1670,"ANESTH,SHOULDER VEIN SURG",,1670,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1680,"ANESTH,SHOULDER CASTING",,1680,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1710,"ANESTH,ELBOW AREA SURGERY",,1710,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1712,"ANESTH,UPPERARM TENDON SURG",,1712,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1714,"ANESTH,UPPERARM TENDON REVISN SURG",,1714,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1716,"ANESTH,BICEPS TENDON REPAIR",,1716,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1730,"ANESTH,ARM/ELBOW BONES,CLOSED PROC",,1730,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,174,"ANESTH,EXCIS RETROPHARYNG TUMOR",,174,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,100,"ANESTH,SALIVARY GLAND W/BX",,100,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1732,"ANESTH,DX ARTHROSCOPIC PROC ELBOW JOINT",,1732,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1740,"ANESTH,ELBOW,NOS",,1740,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1742,"ANESTH,HUMERUS SURGERY",,1742,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1744,"ANESTH,HUMERUS REPAIR",,1744,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1756,"ANESTH,RADICAL HUMERUS SURG",,1756,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1758,"ANESTH,HUMERAL LESION SURG",,1758,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1760,"ANESTH,ELBOW REPLACEMENT",,1760,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1770,"ANESTH,UPPERARM ARTERY SURG",,1770,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1772,"ANESTH,UPPERARM EMBOLECTOMY",,1772,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1780,"ANESTH,UPPER ARM VEIN SURG",,1780,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,176,"ANESTH,PHARYNX SURG RADICAL",,176,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1782,"ANESTH,UPPER ARM VEIN REPAIR",,1782,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1810,"ANESTH,LOWER ARM SURGERY",,1810,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1820,"ANESTH,FOREARM BONES,CLOSED PROC",,1820,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1830,"ANESTH,DISTAL RADIUS/ULNA WRIST/HAND,NOS",,1830,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1832,"ANESTH,WRIST REPLACEMENT",,1832,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1840,"ANESTH,LOWER ARM ARTERY SURG",,1840,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1842,"ANESTH,LOWER ARM EMBOLECTOMY",,1842,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1844,"ANESTH,LOWER ARM,VASC SHUNT SURG",,1844,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1850,"ANESTH,LOWER ARM VEIN SURG",,1850,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1852,"ANESTH,LOWER ARM VEIN REPAIR",,1852,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,190,"ANESTH,FACIAL BONE SURGERY",,190,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1860,"ANESTH,LOWER ARM CASTING",,1860,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1916,"ANESTH,DX ARTERIOGRAPHY/VENOGRAPHY",,1916,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1920,"ANESTH,CARDIAC CATH W/CORON ART & VENT",,1920,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1922,"ANESTH,CAT/MRI SCAN,RADIATN THERAPY",,1922,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1990,"PHYS SUPPORT,BRAIN-DEAD ORGAN DONOR",,1990,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1999,UNLISTED ANESTH PROCEDURE,,1999,964,$220.00 ,$220.00 ,$61.60 ,$201.30 ,$154.00 ,$184.14 ,$201.30 ,$201.30 ,$201.30 ,$81.07 ,$132.00 ,$66.00 ,$198.00 ,$165.00 ,$176.00 ,$182.60
Hoopeston Regional Hlth Center,192,"ANESTH,RADICAL FACIAL BONE SURGERY",,192,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,210,"ANESTH,OPEN HEAD SURGERY",,210,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,212,"ANESTH,SKULL SURG SUBDUR TAP",,212,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,214,"ANESTH,SKULL SURG BURR HOLE",,214,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,215,"ANESTH, CRANIOPLASTY",,215,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,216,"ANESTH,HEAD VESSEL SURGERY",,216,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,218,"ANESTH,SPECIAL HEAD SURGERY",,218,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,220,"ANESTH,INTRACRAN PROC; CSF SHUNT PROC",,220,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,102,"ANESTH,CLEFT LIP REPAIR",,102,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,222,"ANESTH,INTRACRAN NERVE COAGULATN",,222,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,300,"ANESTH,SKIN SURG HEAD/NECK",,300,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,320,"ANESTH,NECK ORG PROC; NOS, AGE 1 YR/OLD",,320,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,322,"ANESTH,NEEDLE BX THYROID",,322,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,350,"ANESTH,NECK VESSEL SURGERY NOS",,350,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,352,"ANESTH,NECK VESSEL SURG SIMPL LIGAT",,352,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,400,"ANESTH,SKIN SURG THORAX/EXTR",,400,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,402,"ANESTH,SURG BREAST RECONSTRUCTIVE",,402,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,404,"ANESTH,SURG BREAST RAD MASTEC",,404,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,406,"ANESTH,SURG BREAST RAD MAST W NODE",,406,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,103,"ANESTH,BLEPHAROPLASTY",,103,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,410,"ANESTH,CORRECT HEART RHYTHM",,410,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,450,"ANESTH,SURG CLAVICLE/SCAPULA",,450,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,454,"ANESTH,CLAVICLE BIOPSY",,454,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,470,"ANESTH,PARTIAL RIB RESECTN",,470,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,731,ANESTHESIA UPPER GI ENDOSCOPIC PX NOS,,731,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,732,ANESTHESIA UPPER GI ENDOSCOPIC PX ERCP,,732,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,811,ANESTHESIA LOWER INTST ENDOSCOPIC PX NOS,,811,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,812,ANESTHESIA LOWER INTST ENDOSCOPIC PX SCR COLSC,,812,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,813,ANESTHESIA COMBINED UPPER&LOWER GI ENDOSCOPIC PX,,813,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,472,"ANESTH,CHEST WALL REPAIR",,472,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,474,"ANESTH,CHEST WALL REPAIR EXTENSIVE",,474,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,500,"ANESTH,ESOPHAGEAL SURGERY",,500,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,520,"ANESTH,CHEST PROC CLOSED,NOS",,520,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,522,"ANESTH,CHEST PLEURAL BIOPSY",,522,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,104,"ANESTH,ELECTROSHOCK/ ECT",,104,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,524,"ANESTH,CHEST DRAINAGE",,524,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,528,"ANESTH,MEDIASTINOSCOPY",,528,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,530,"ANESTH,PACEMAKER INSERTION",,530,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,532,"ANESTH,CENTRL VASCULAR ACCESS",,532,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,534,"ANESTH,CARDIOVERTER/DEFIB",,534,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,540,"ANESTH,CHEST SURGERY,THORACOTOMY",,540,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,542,"ANESTH,CHEST DECORTICATION",,542,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,546,"ANESTH,LUNG RESEC,THORACOPLASTY",,546,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,548,"ANESTH,TRACH,BRONCHI INTRATHOR SURG",,548,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,560,"ANESTH,OPEN HEART; W/O PUMP OXYEGENATOR",,560,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,120,"ANESTH,EAR SURGERY",,120,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,562,"ANESTH,OPEN HEART SURGERY+PUMP",,562,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,580,"ANESTH,HEART/LUNG TRANSPLANT",,580,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,600,"ANESTH,CERV SPINE,CORD SURGERY",,600,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,604,"ANESTH,CERV SPINE, SITTING POSITION",,604,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,620,"ANESTH,THOR SPINE,CORD SURGERY",,620,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,630,"ANESTH,LUMBAR SPINE,CORD SURGERY",,630,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,632,"ANESTH,LUMBAR SYMPATHECTOMY",,632,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,670,"ANESTH,EXTENSIVE SPINE,CORD PROCED",,670,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,124,"ANESTH,EAR EXAM",,124,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,700,"ANESTH,ABD WALL,UPER ANTER,SURG",,700,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,702,"ANESTH,FOR LIVER BIOPSY",,702,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,730,"ANESTH,ABD WALL,UPPER POST,SURG",,730,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,750,"ANESTH,REPAIR UPPER ABD HERNIA NOS",,750,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,752,"ANESTH,REPAIR UP HERNIA LUMBAR/VENTR",,752,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,754,"ANESTH,REPAIR UP HERNIA OMPHALOCELE",,754,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,756,"ANESTH,REPAIR UP HERNIA DIAPHRAGM",,756,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,770,"ANESTH,MAJOR ABD BLOOD VESSEL REPAIR",,770,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,326,"ANESTH,LARYNX/TRACH PROC; CHILDREN <1 YR",,326,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,529,"ANESTH, CHEST PARTITION VIEW",,529,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,537,"ANESTH,CARD ELECTROPHYS PROC",,537,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,790,"ANESTH,SURG UPPER ABDOMEN",,790,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,126,"ANESTH,TYMPANOTOMY",,126,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,539,"ANESTH,TRACHEOBRONCHIAL RECONSTRUCT",,539,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,541,"ANESTH,THORACOTOMY PROC, W/1 LUNG VENT",,541,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,550,"ANESTH,STERNAL DEBRIDEMENT",,550,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,563,"ANESTH,OPEN HEART,PUMP+HYPOTHERM",,563,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,566,"ANESTH,DIRECT CABG W/O PUMP OXYGENATOR",,566,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,635,"ANESTH,LUMBAR PUNCTURE",,635,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,640,"ANESTH,CLOSED MANIPULATION, SPINE C/T/L",,640,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,797,"ANESTH,GASTRIC RESTRICT, MORBID OBESITY",,797,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,834,"ANESTH,REPAIR LO ABD HERNIA NOS, < 1 YR",,834,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,836,"ANESTH,REP LO ABD HERN NOS, PREM <50 WKS",,836,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,792,"ANESTH,PARTIAL LIVER REMOVAL",,792,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,851,"ANESTH,TUBAL LIGATION/TRANSECTION",,851,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,921,"ANESTH,VASECTOMY, UNILAT/BILAT",,921,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1112,"ANESTH,BONE MARROW ASP/BX ILIAC CRST",,1112,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1173,"ANESTH, FX REPAIR, PELVIS",,1173,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1215,"ANESTH,REVISE TOTAL HIP ARTHROPLASTY",,1215,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1829,"ANESTH,DX ARTHROSCOPIC PROC WRIST",,1829,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1924,"ANESTH,INTER RAD,ARTERIAL SYS,NOS",,1924,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1925,"ANESTH,INTER RAD, ARTERIAL, CAROTID/CORONARY",,1925,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1926,"ANESTH,INTER RAD,ARTERIAL, INTRACRA/INTRACAR/AORT",,1926,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1930,"ANESTH,INTER RAD,VENOUS/LYMPH SYS,NOS",,1930,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,794,"ANESTH,PANCREAS REMOVAL",,794,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1931,"ANESTH,INTER RAD,VENOUS/LYMPH,INTRAHEPAT/PORTAL CIRC",,1931,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1932,"ANESTH,INTER RAD,VENOUS/LYMPH,INTRATHORACIC/JUGULAR",,1932,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1933,"ANESTH,INTER RAD,VENOUS/LYMPH,INTRACRANIAL",,1933,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1958,"ANESTH, ANTEPARTUM MANIPUL",,1958,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1960,"ANESTH,VAGINAL DELIVERY ONLY",,1960,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1961,"ANESTH,CESAREAN DELIVERY ONLY",,1961,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1962,"ANESTH,URG HYSTERECTOMY FOL DELIVERY",,1962,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1963,"ANESTH,CESAREAN HYST W/O LABOR ANAL/ANES",,1963,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1967,"ANESTH, NEURAXIAL LABOR, PLAN VAG DEL",,1967,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1968,"ANESTH,CES DEL AFTER NEURAXIAL ANESTH",,1968,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,796,"ANESTH,FOR LIVER TRANSPLANT",,796,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1969,"ANESTH,CES HYST FOL NEURAXIAL ANAL/ANES",,1969,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1991,ANES DX/THER NRV BLK/NJX OTH/THN PRONE POS,,1991,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1992,ANES DX/THER NERVE BLOCK/INJECTION PRONE POS,,1992,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,800,"ANESTH,ABD WALL,LOWER ANT,SURG",,800,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,802,"ANESTH,FAT LAYER REMOVAL",,802,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,820,"ANESTH,ABD WALL,LOWER POST,SURG",,820,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,830,"ANESTH,REPAIR LO ABD HERNIA NOS",,830,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,832,"ANESTH,REPAIR LO HERNIA VENTR/INCIS",,832,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,840,"ANESTH,SURG LOWER ABDOMEN",,840,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,140,"ANESTH,PROCEDURES ON EYE",,140,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,211,"ANESTH, INTRACRANIAL HEMATOMA EVACUATION",,211,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,561,"ANESTH, HEART SURG < AGE 1",,561,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,567,"ANESTH, DIRECT CABG W PUMP OXYGENATOR",,567,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,625,"ANESTH,TRANSTHORACIC SPINE SURG W/O 1 LUNG VENT",,625,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,626,"ANESTH,TRANSTHORACIC SPINE SURG W/ 1 LUNG VENT",,626,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1935,"ANESTH,PERC IMAGE GUIDE SPINAL PROC, DIAG",,1935,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1936,"ANESTH,PERC IMAGE GUIDE SPINAL PROC, THER",,1936,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,842,"ANESTH,AMNIOCENTESIS",,842,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1965,ANESTHESIA FOR MEDICAL PROCEDURE,,1965,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,1966,"ANESTH, INDUCED AB PROCEDURE",,1966,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,844,"ANESTH,ABD-PERINEAL RESECTION",,844,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,846,"ANESTH,RADICAL HYSTERECTOMY",,846,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,848,"ANESTH,PELVIC EXENTERATION",,848,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,860,"ANESTH,SURG LOW ABD,EXTRAPERINTONEAL",,860,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,862,"ANESTH,KIDNEY,PROX URETER SURG",,862,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,864,"ANESTH,REMOVAL OF BLADDER",,864,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,865,"ANESTH,REMOVAL OF PROSTATE",,865,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,866,"ANESTH,REMOVAL OF ADRENAL",,866,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,868,"ANESTH,KIDNEY TRANSPLANT",,868,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,142,"ANESTH, LENS SURGERY",,142,964,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,99080,SPECIAL REPORTS OR FORMS,,99080,969,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,1123F,"ADV CARE PLAN DISCUSSED, PLAN OR SURROGATE DOCUMENTED",,1123F,969,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,1124F,"ADV CARE PLAN DISCUSSED, UNABLE/UNWILL DOC PLAN OR SURROGATE",,1124F,969,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,8317899,LABORATORY SERVICES,,87899,971,$72.00 ,$72.00 ,$20.16 ,$65.88 ,$50.40 ,$60.26 ,$65.88 ,$65.88 ,$65.88 ,$26.53 ,$43.20 ,$21.60 ,$64.80 ,$54.00 ,$57.60 ,$59.76
Hoopeston Regional Hlth Center,85060,BLOOD SMEAR INTERPRETATION,,85060,971,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,88307,"SURG PATH,LEVEL V",,88307,971,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,74740,X-RAY HYSTEROSALPINGOGRAM,,74740,972,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,76815,"US,PREGNANT UTERUS,LIMITED, 1/> FETUSES",,76815,972,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,76857,SONO PELVIS LIMITED,,76857,972,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,76946,SONO GUIDE AMNIOCENTESIS,,76946,972,$770.00 ,$770.00 ,$215.60 ,$704.55 ,$539.00 ,$644.49 ,$704.55 ,$704.55 ,$704.55 ,$283.75 ,$462.00 ,$231.00 ,$693.00 ,$577.50 ,$616.00 ,$639.10
Hoopeston Regional Hlth Center,76831,"SONO EXAM, HYSTEROSONOGRAPHY",,76831,972,$820.00 ,$820.00 ,$229.60 ,$750.30 ,$574.00 ,$686.34 ,$750.30 ,$750.30 ,$750.30 ,$302.17 ,$492.00 ,$246.00 ,$738.00 ,$615.00 ,$656.00 ,$680.60
Hoopeston Regional Hlth Center,99281,EMERGENCY DEPARTMENT VISIT LIMITED/MINOR PROB,,99281,981,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,99282,EMERGENCY DEPARTMENT VISIT LOW/MODER SEVERITY,,99282,981,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,99283,EMERGENCY DEPARTMENT VISIT MODERATE SEVERITY,,99283,981,$560.00 ,$560.00 ,$156.80 ,$512.40 ,$392.00 ,$468.72 ,$512.40 ,$512.40 ,$512.40 ,$206.36 ,$336.00 ,$168.00 ,$504.00 ,$420.00 ,$448.00 ,$464.80
Hoopeston Regional Hlth Center,99284,EMERGENCY DEPARTMENT VISIT HIGH/URGENT SEVERITY,,99284,981,$820.00 ,$820.00 ,$229.60 ,$750.30 ,$574.00 ,$686.34 ,$750.30 ,$750.30 ,$750.30 ,$302.17 ,$492.00 ,$246.00 ,$738.00 ,$615.00 ,$656.00 ,$680.60
Hoopeston Regional Hlth Center,99285,EMERGENCY DEPT VISIT HIGH SEVERITY&THREAT FUNCJ,,99285,981,"$1,270.00 ","$1,270.00 ",$355.60 ,"$1,162.05 ",$889.00 ,"$1,062.99 ","$1,162.05 ","$1,162.05 ","$1,162.05 ",$468.00 ,$762.00 ,$381.00 ,"$1,143.00 ",$952.50 ,"$1,016.00 ","$1,054.10 "
Hoopeston Regional Hlth Center,9493227,XTRNL ECH CONT W/I&R UP TO 48HRS,,93227,985,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,9499222,INITIAL HOSPITAL CARE,,99222,987,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,99217,OBSERVATION CARE DISCHARGE MANAGEMENT,,99217,987,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,99218,INITIAL OBSERVATION CARE/DAY LEVEL 1,,99218,987,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,99219,INITIAL OBSERVATION CARE/DAY LEVEL 2,,99219,987,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,99220,INITIAL OBSERVATION CARE/DAY LEVEL 3,,99220,987,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,99221,INITIAL HOSPITAL CARE/DAY LEVEL 1,,99221,987,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,99222,INITIAL HOSPITAL CARE/DAY LEVEL 2,,99222,987,$495.00 ,$495.00 ,$138.60 ,$452.93 ,$346.50 ,$414.32 ,$452.93 ,$452.93 ,$452.93 ,$182.41 ,$297.00 ,$148.50 ,$445.50 ,$371.25 ,$396.00 ,$410.85
Hoopeston Regional Hlth Center,99223,INITIAL HOSPITAL CARE/DAY LEVEL 3,,99223,987,$650.00 ,$650.00 ,$182.00 ,$594.75 ,$455.00 ,$544.05 ,$594.75 ,$594.75 ,$594.75 ,$239.53 ,$390.00 ,$195.00 ,$585.00 ,$487.50 ,$520.00 ,$539.50
Hoopeston Regional Hlth Center,99231,SBSQ HOSPITAL CARE/DAY LEVEL 1,,99231,987,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,99232,SBSQ HOSPITAL CARE/DAY LEVEL 2,,99232,987,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,99233,SBSQ HOSPITAL CARE/DAY LEVEL 3,,99233,987,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,99238,"HOSPITAL DISCHARGE DAY,<30 MIN",,99238,987,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,99239,"HOSPITAL DISCHARGE DAY,>30 MIN",,99239,987,$355.00 ,$355.00 ,$99.40 ,$324.83 ,$248.50 ,$297.14 ,$324.83 ,$324.83 ,$324.83 ,$130.82 ,$213.00 ,$106.50 ,$319.50 ,$266.25 ,$284.00 ,$294.65
Hoopeston Regional Hlth Center,99251,PR INITL INPATIENT CONSULT NEW/ESTAB PT LEVEL 1,,99251,987,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,99252,PR INITL INPATIENT CONSULT NEW/ESTAB PT LEVEL 2,,99252,987,$350.00 ,$350.00 ,$98.00 ,$320.25 ,$245.00 ,$292.95 ,$320.25 ,$320.25 ,$320.25 ,$128.98 ,$210.00 ,$105.00 ,$315.00 ,$262.50 ,$280.00 ,$290.50
Hoopeston Regional Hlth Center,99253,PR INITL INPATIENT CONSULT NEW/ESTAB PT LEVEL 3,,99253,987,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,99254,PR INITL INPATIENT CONSULT NEW/ESTAB PT LEVEL 4,,99254,987,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,99255,PR INITIAL INPATIENT CONSULT NEW/ESTAB PT LEVEL 5,,99255,987,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,99356,PROLONGED SVC I/P OR OBS SETTING 1ST HOUR,,99356,987,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,99357,PROLONGED SVC I/P REQ UNIT/FLOOR TIME EA 30 MIN,,99357,987,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,99234,OBSERVATION/INPATIENT HOSPITAL CARE LEVEL 1,,99234,987,$480.00 ,$480.00 ,$134.40 ,$439.20 ,$336.00 ,$401.76 ,$439.20 ,$439.20 ,$439.20 ,$176.88 ,$288.00 ,$144.00 ,$432.00 ,$360.00 ,$384.00 ,$398.40
Hoopeston Regional Hlth Center,99235,OBSERVATION/INPATIENT HOSPITAL CARE LEVEL 2,,99235,987,$740.00 ,$740.00 ,$207.20 ,$677.10 ,$518.00 ,$619.38 ,$677.10 ,$677.10 ,$677.10 ,$272.69 ,$444.00 ,$222.00 ,$666.00 ,$555.00 ,$592.00 ,$614.20
Hoopeston Regional Hlth Center,99236,OBSERVATION/INPATIENT HOSPITAL CARE LEVEL 3,,99236,987,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,99460,"INITIAL NORMAL NEWBORN CARE, HOSPITAL OR BIRTH CENTER",,99460,987,$365.00 ,$365.00 ,$102.20 ,$333.98 ,$255.50 ,$305.51 ,$333.98 ,$333.98 ,$333.98 ,$134.50 ,$219.00 ,$109.50 ,$328.50 ,$273.75 ,$292.00 ,$302.95
Hoopeston Regional Hlth Center,99462,"SUBSEQUENT HOSPITAL CARE, NORMAL NEWBORN",,99462,987,$190.00 ,$190.00 ,$53.20 ,$173.85 ,$133.00 ,$159.03 ,$173.85 ,$173.85 ,$173.85 ,$70.02 ,$114.00 ,$57.00 ,$171.00 ,$142.50 ,$152.00 ,$157.70
Hoopeston Regional Hlth Center,99463,"INITIAL NORMAL NEWBORN CARE, SAME DAY DISCHARGE",,99463,987,$415.00 ,$415.00 ,$116.20 ,$379.73 ,$290.50 ,$347.36 ,$379.73 ,$379.73 ,$379.73 ,$152.93 ,$249.00 ,$124.50 ,$373.50 ,$311.25 ,$332.00 ,$344.45
Hoopeston Regional Hlth Center,99464,ATTN AT DELIVERY 1ST STABILIZATION OF NEWBORN,,99464,987,$485.00 ,$485.00 ,$135.80 ,$443.78 ,$339.50 ,$405.95 ,$443.78 ,$443.78 ,$443.78 ,$178.72 ,$291.00 ,$145.50 ,$436.50 ,$363.75 ,$388.00 ,$402.55
Hoopeston Regional Hlth Center,99465,DELIVERY/BIRTHING ROOM RESUSCITATION,,99465,987,$940.00 ,$940.00 ,$263.20 ,$860.10 ,$658.00 ,$786.78 ,$860.10 ,$860.10 ,$860.10 ,$346.39 ,$564.00 ,$282.00 ,$846.00 ,$705.00 ,$752.00 ,$780.20
Hoopeston Regional Hlth Center,99468,"INITIAL HOSP NEONATE 28 DAY OR LESS, CRITICALLY ILL",,99468,987,"$4,350.00 ","$4,350.00 ","$1,218.00 ","$3,980.25 ","$3,045.00 ","$3,640.95 ","$3,980.25 ","$3,980.25 ","$3,980.25 ","$1,602.98 ","$2,610.00 ","$1,305.00 ","$3,915.00 ","$3,262.50 ","$3,480.00 ","$3,610.50 "
Hoopeston Regional Hlth Center,99224,SBSQ OBSERVATION CARE/DAY LEVEL 1,,99224,987,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,99225,SBSQ OBSERVATION CARE/DAY LEVEL 2,,99225,987,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,99226,SBSQ OBSERVATION CARE/DAY LEVEL 3,,99226,987,$330.00 ,$330.00 ,$92.40 ,$301.95 ,$231.00 ,$276.21 ,$301.95 ,$301.95 ,$301.95 ,$121.61 ,$198.00 ,$99.00 ,$297.00 ,$247.50 ,$264.00 ,$273.90
Hoopeston Regional Hlth Center,7579639,Pr Vitascrub,,0,990,$70.00 ,$70.00 ,$19.60 ,$64.05 ,$49.00 ,$58.59 ,$64.05 ,$64.05 ,$64.05 ,$25.80 ,$42.00 ,$21.00 ,$63.00 ,$52.50 ,$56.00 ,$58.10
Hoopeston Regional Hlth Center,7579638,Pr Oilacleanse,,0,990,$43.00 ,$43.00 ,$12.04 ,$39.35 ,$30.10 ,$35.99 ,$39.35 ,$39.35 ,$39.35 ,$15.85 ,$25.80 ,$12.90 ,$38.70 ,$32.25 ,$34.40 ,$35.69
Hoopeston Regional Hlth Center,9380500,LAB PATHOLOGY CONSULTATION REF,,80500,,$76.00 ,$76.00 ,$21.28 ,$69.54 ,$53.20 ,$63.61 ,$69.54 ,$69.54 ,$69.54 ,$28.01 ,$45.60 ,$22.80 ,$68.40 ,$57.00 ,$60.80 ,$63.08
Hoopeston Regional Hlth Center,9381041,"ISOAGGLUTININ TITER, ANTI-A REF",,86886,,$21.00 ,$21.00 ,$5.88 ,$19.22 ,$14.70 ,$17.58 ,$19.22 ,$19.22 ,$19.22 ,$7.74 ,$12.60 ,$6.30 ,$18.90 ,$15.75 ,$16.80 ,$17.43
Hoopeston Regional Hlth Center,9381042,"FRANCISELLA TULARENSIS ANTIOBODY, IGM/IGA REF",,86668,,$57.00 ,$57.00 ,$15.96 ,$52.16 ,$39.90 ,$47.71 ,$52.16 ,$52.16 ,$52.16 ,$21.00 ,$34.20 ,$17.10 ,$51.30 ,$42.75 ,$45.60 ,$47.31
Hoopeston Regional Hlth Center,9381779,"NEISSERIA GONORRHOEAE BY RT, PCR, REF",,9381779,,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,9401001,Cdsm evicore,,G1001,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,9401002,Cdsm medcurrent,,G1002,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,9401003,Cdsm medicalis,,G1003,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,9401004,Cdsm ndsc,,G1004,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,9401007,Cdsm aim,,G1007,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,9401008,Cdsm cranberry pk,,G1008,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,9401009,Cdsm sage health,,G1009,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,9401010,Cdsm stanson,,G1010,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,9401011,Cdsm qualified nos,,G1011,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,20604,ARTHROCNT ASPIR&/INJ SMALL JT/BURSAW/US REC RPRT,,20604,,$500.00 ,$500.00 ,$140.00 ,$457.50 ,$350.00 ,$418.50 ,$457.50 ,$457.50 ,$457.50 ,$184.25 ,$300.00 ,$150.00 ,$450.00 ,$375.00 ,$400.00 ,$415.00
Hoopeston Regional Hlth Center,20606,ARTHROCENTESIS ASPIR&/INJ INTERM JT/BURS W/US,,20606,,$570.00 ,$570.00 ,$159.60 ,$521.55 ,$399.00 ,$477.09 ,$521.55 ,$521.55 ,$521.55 ,$210.05 ,$342.00 ,$171.00 ,$513.00 ,$427.50 ,$456.00 ,$473.10
Hoopeston Regional Hlth Center,33948,ECMO/ECLS DAILY MANAGEMENT EACH DAY VENO-VENOUS,,33948,,"$2,520.00 ","$2,520.00 ",$705.60 ,"$2,305.80 ","$1,764.00 ","$2,109.24 ","$2,305.80 ","$2,305.80 ","$2,305.80 ",$928.62 ,"$1,512.00 ",$756.00 ,"$2,268.00 ","$1,890.00 ","$2,016.00 ","$2,091.60 "
Hoopeston Regional Hlth Center,46601,ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT,,46601,,$860.00 ,$860.00 ,$240.80 ,$786.90 ,$602.00 ,$719.82 ,$786.90 ,$786.90 ,$786.90 ,$316.91 ,$516.00 ,$258.00 ,$774.00 ,$645.00 ,$688.00 ,$713.80
Hoopeston Regional Hlth Center,46607,ANOSCOPY DX W/HRA &CHEM AGNTS ENHANCEMENT W/BX,,46607,,"$1,750.00 ","$1,750.00 ",$490.00 ,"$1,601.25 ","$1,225.00 ","$1,464.75 ","$1,601.25 ","$1,601.25 ","$1,601.25 ",$644.88 ,"$1,050.00 ",$525.00 ,"$1,575.00 ","$1,312.50 ","$1,400.00 ","$1,452.50 "
Hoopeston Regional Hlth Center,52441,CYSTO INSERTION TRANSPROSTATIC IMPLANT SINGLE,,52441,,"$9,460.00 ","$9,460.00 ","$2,648.80 ","$8,655.90 ","$6,622.00 ","$7,918.02 ","$8,655.90 ","$8,655.90 ","$8,655.90 ","$3,486.01 ","$5,676.00 ","$2,838.00 ","$8,514.00 ","$7,095.00 ","$7,568.00 ","$7,851.80 "
Hoopeston Regional Hlth Center,52442,CYSTO INSERTION TRANSPROSTATIC IMPLANT EA ADDL,,52442,,"$7,310.00 ","$7,310.00 ","$2,046.80 ","$6,688.65 ","$5,117.00 ","$6,118.47 ","$6,688.65 ","$6,688.65 ","$6,688.65 ","$2,693.74 ","$4,386.00 ","$2,193.00 ","$6,579.00 ","$5,482.50 ","$5,848.00 ","$6,067.30 "
Hoopeston Regional Hlth Center,99188,APPLICATION TOPICAL FLUORIDE VARNISH BY PHS/QHP,,99188,,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,99498,ADVANCE CARE PLANNING EA ADDL 30 MINS,,99498,,$270.00 ,$270.00 ,$75.60 ,$247.05 ,$189.00 ,$225.99 ,$247.05 ,$247.05 ,$247.05 ,$99.50 ,$162.00 ,$81.00 ,$243.00 ,$202.50 ,$216.00 ,$224.10
Hoopeston Regional Hlth Center,96156,HEALTH BEHAVIOR ASSESSMENT/RE-ASSESSMENT,,96156,,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,96158,HEALTH BEHAVIOR IVNTJ INDIV F2F 1ST 30 MIN,,96158,,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,96159,HEALTH BEHAVIOR IVNTJ INDIV F2F EA ADDL 15 MIN,,96159,,$82.00 ,$82.00 ,$22.96 ,$75.03 ,$57.40 ,$68.63 ,$75.03 ,$75.03 ,$75.03 ,$30.22 ,$49.20 ,$24.60 ,$73.80 ,$61.50 ,$65.60 ,$68.06
Hoopeston Regional Hlth Center,96164,HEALTH BEHAVIOR IVNTJ GROUP F2F 1ST 30 MIN,,96164,,$53.00 ,$53.00 ,$14.84 ,$48.50 ,$37.10 ,$44.36 ,$48.50 ,$48.50 ,$48.50 ,$19.53 ,$31.80 ,$15.90 ,$47.70 ,$39.75 ,$42.40 ,$43.99
Hoopeston Regional Hlth Center,96165,HEALTH BEHAVIOR IVNTJ GROUP F2F EA ADDL 15 MIN,,96165,,$27.00 ,$27.00 ,$7.56 ,$24.71 ,$18.90 ,$22.60 ,$24.71 ,$24.71 ,$24.71 ,$9.95 ,$16.20 ,$8.10 ,$24.30 ,$20.25 ,$21.60 ,$22.41
Hoopeston Regional Hlth Center,96167,HEALTH BEHAVIOR IVNTJ FAM W/PT F2F 1ST 30 MIN,,96167,,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,96168,HEALTH BEHAVIOR IVNTJ FAM W/PT F2F EA ADD 15 MIN,,96168,,$91.00 ,$91.00 ,$25.48 ,$83.27 ,$63.70 ,$76.17 ,$83.27 ,$83.27 ,$83.27 ,$33.53 ,$54.60 ,$27.30 ,$81.90 ,$68.25 ,$72.80 ,$75.53
Hoopeston Regional Hlth Center,96170,HEALTH BEHAVIOR IVNTJ FAM W/O PT F2F 1ST 30 MIN,,96170,,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,96171,HEALTH BEHAVIOR IVNTJ FAM W/O PT F2F EA ADDL 15,,96171,,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,99473,SELF-MEAS BP PT EDUCAJ/TRAING & DEV CALIBRATION,,99473,,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,G2086,Off base opioid tx 70min,,G2086,,"$1,200.00 ","$1,200.00 ",$336.00 ,"$1,098.00 ",$840.00 ,"$1,004.40 ","$1,098.00 ","$1,098.00 ","$1,098.00 ",$442.20 ,$720.00 ,$360.00 ,"$1,080.00 ",$900.00 ,$960.00 ,$996.00
Hoopeston Regional Hlth Center,G2087,"Off base opioid tx, 60 m",,G2087,,"$1,080.00 ","$1,080.00 ",$302.40 ,$988.20 ,$756.00 ,$903.96 ,$988.20 ,$988.20 ,$988.20 ,$397.98 ,$648.00 ,$324.00 ,$972.00 ,$810.00 ,$864.00 ,$896.40
Hoopeston Regional Hlth Center,G2088,"Off base opioid tx, add30",,G2088,,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,82803,"BLOOD GASES: PH, PO2 & PCO2",,82803,,$175.00 ,$175.00 ,$49.00 ,$160.13 ,$122.50 ,$146.48 ,$160.13 ,$160.13 ,$160.13 ,$64.49 ,$105.00 ,$52.50 ,$157.50 ,$131.25 ,$140.00 ,$145.25
Hoopeston Regional Hlth Center,83036,GLYCOSYLATED HEMOGLOBIN TEST,,83036,,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,83605,ASSAY OF LACTIC ACID,,83605,,$140.00 ,$140.00 ,$39.20 ,$128.10 ,$98.00 ,$117.18 ,$128.10 ,$128.10 ,$128.10 ,$51.59 ,$84.00 ,$42.00 ,$126.00 ,$105.00 ,$112.00 ,$116.20
Hoopeston Regional Hlth Center,83986,PH BODY FLUID NOS,,83986,,$40.00 ,$40.00 ,$11.20 ,$36.60 ,$28.00 ,$33.48 ,$36.60 ,$36.60 ,$36.60 ,$14.74 ,$24.00 ,$12.00 ,$36.00 ,$30.00 ,$32.00 ,$33.20
Hoopeston Regional Hlth Center,85025,COMPLETE CBC & AUTO DIFF WBC,,85025,,$80.00 ,$80.00 ,$22.40 ,$73.20 ,$56.00 ,$66.96 ,$73.20 ,$73.20 ,$73.20 ,$29.48 ,$48.00 ,$24.00 ,$72.00 ,$60.00 ,$64.00 ,$66.40
Hoopeston Regional Hlth Center,85379,"FIBRIN DEGRADPRODUCTS,D-DIMER, QUANT",,85379,,$160.00 ,$160.00 ,$44.80 ,$146.40 ,$112.00 ,$133.92 ,$146.40 ,$146.40 ,$146.40 ,$58.96 ,$96.00 ,$48.00 ,$144.00 ,$120.00 ,$128.00 ,$132.80
Hoopeston Regional Hlth Center,87101,CULTURE FUNGI-SKIN HAIR NAILS,,87101,,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,89310,"SEMEN ANALYSIS,MOTIL & COUNT W/O HUHNER",,89310,,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,90849,MULTIP FAMILY-GROUP PSYCHOTHERAPY,,90849,,$255.00 ,$255.00 ,$71.40 ,$233.33 ,$178.50 ,$213.44 ,$233.33 ,$233.33 ,$233.33 ,$93.97 ,$153.00 ,$76.50 ,$229.50 ,$191.25 ,$204.00 ,$211.65
Hoopeston Regional Hlth Center,90870,MEDICAL SERVICE,,90870,,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,90880,MEDICAL SERVICE,,90880,,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,90882,MEDICAL SERVICE,,90882,,$235.00 ,$235.00 ,$65.80 ,$215.03 ,$164.50 ,$196.70 ,$215.03 ,$215.03 ,$215.03 ,$86.60 ,$141.00 ,$70.50 ,$211.50 ,$176.25 ,$188.00 ,$195.05
Hoopeston Regional Hlth Center,90887,MEDICAL SERVICE,,90887,,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,90889,MEDICAL SERVICE,,90889,,$230.00 ,$230.00 ,$64.40 ,$210.45 ,$161.00 ,$192.51 ,$210.45 ,$210.45 ,$210.45 ,$84.76 ,$138.00 ,$69.00 ,$207.00 ,$172.50 ,$184.00 ,$190.90
Hoopeston Regional Hlth Center,90935,HEMODIALYSIS PROCEDURE W/ PHYS/QHP EVALUATION,,90935,,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,90937,"HEMODIALYSIS, REPEATED EVAL.",,90937,,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,91065,BREATH HYDROGEN/METHANE TEST,,91065,,$485.00 ,$485.00 ,$135.80 ,$443.78 ,$339.50 ,$405.95 ,$443.78 ,$443.78 ,$443.78 ,$178.72 ,$291.00 ,$145.50 ,$436.50 ,$363.75 ,$388.00 ,$402.55
Hoopeston Regional Hlth Center,92002,"EYE EXAM, NEW PATIENT,INTERMED",,92002,,$205.00 ,$205.00 ,$57.40 ,$187.58 ,$143.50 ,$171.59 ,$187.58 ,$187.58 ,$187.58 ,$75.54 ,$123.00 ,$61.50 ,$184.50 ,$153.75 ,$164.00 ,$170.15
Hoopeston Regional Hlth Center,92004,"EYE EXAM, NEW PATIENT,COMPREHESV",,92004,,$300.00 ,$300.00 ,$84.00 ,$274.50 ,$210.00 ,$251.10 ,$274.50 ,$274.50 ,$274.50 ,$110.55 ,$180.00 ,$90.00 ,$270.00 ,$225.00 ,$240.00 ,$249.00
Hoopeston Regional Hlth Center,92511,NASOPHARYNGOSCOPY,,92511,,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,92557,COMPREHENSIVE HEARING TEST,,92557,,$225.00 ,$225.00 ,$63.00 ,$205.88 ,$157.50 ,$188.33 ,$205.88 ,$205.88 ,$205.88 ,$82.91 ,$135.00 ,$67.50 ,$202.50 ,$168.75 ,$180.00 ,$186.75
Hoopeston Regional Hlth Center,92960,"CARDIOVERSION, ELECTIVE;EXTERN",,92960,,$960.00 ,$960.00 ,$268.80 ,$878.40 ,$672.00 ,$803.52 ,$878.40 ,$878.40 ,$878.40 ,$353.76 ,$576.00 ,$288.00 ,$864.00 ,$720.00 ,$768.00 ,$796.80
Hoopeston Regional Hlth Center,93503,INSERT/PLACE FLOW DIRECT CATH,,93503,,"$1,450.00 ","$1,450.00 ",$406.00 ,"$1,326.75 ","$1,015.00 ","$1,213.65 ","$1,326.75 ","$1,326.75 ","$1,326.75 ",$534.33 ,$870.00 ,$435.00 ,"$1,305.00 ","$1,087.50 ","$1,160.00 ","$1,203.50 "
Hoopeston Regional Hlth Center,94070,"EVAL OF BRONCHOSPASM,PROLONGED",,94070,,$610.00 ,$610.00 ,$170.80 ,$558.15 ,$427.00 ,$510.57 ,$558.15 ,$558.15 ,$558.15 ,$224.79 ,$366.00 ,$183.00 ,$549.00 ,$457.50 ,$488.00 ,$506.30
Hoopeston Regional Hlth Center,94762,"NONINVASV OXYGEN SATUT,CONTINUOUS",,94762,,$165.00 ,$165.00 ,$46.20 ,$150.98 ,$115.50 ,$138.11 ,$150.98 ,$150.98 ,$150.98 ,$60.80 ,$99.00 ,$49.50 ,$148.50 ,$123.75 ,$132.00 ,$136.95
Hoopeston Regional Hlth Center,95044,ALLERGY PATCH TESTS,,95044,,$40.00 ,$40.00 ,$11.20 ,$36.60 ,$28.00 ,$33.48 ,$36.60 ,$36.60 ,$36.60 ,$14.74 ,$24.00 ,$12.00 ,$36.00 ,$30.00 ,$32.00 ,$33.20
Hoopeston Regional Hlth Center,95145,"PROFES SVC,IMMUNOTHERAPY,1 INSECT VENOM",,95145,,$77.00 ,$77.00 ,$21.56 ,$70.46 ,$53.90 ,$64.45 ,$70.46 ,$70.46 ,$70.46 ,$28.37 ,$46.20 ,$23.10 ,$69.30 ,$57.75 ,$61.60 ,$63.91
Hoopeston Regional Hlth Center,95147,"ANTIGEN RX SERV,INSECT,3 VENOMS",,95147,,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,95148,"ANTIGEN RX SERV,INSECT,4 VENOMS",,95148,,$145.00 ,$145.00 ,$40.60 ,$132.68 ,$101.50 ,$121.37 ,$132.68 ,$132.68 ,$132.68 ,$53.43 ,$87.00 ,$43.50 ,$130.50 ,$108.75 ,$116.00 ,$120.35
Hoopeston Regional Hlth Center,95149,"ANTIGEN RX SERV,INSECT,5 VENOMS",,95149,,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,95165,"PROFES SVC,IMMUNOTHER,SINGLE/MULT AGS",,95165,,$39.00 ,$39.00 ,$10.92 ,$35.69 ,$27.30 ,$32.64 ,$35.69 ,$35.69 ,$35.69 ,$14.37 ,$23.40 ,$11.70 ,$35.10 ,$29.25 ,$31.20 ,$32.37
Hoopeston Regional Hlth Center,95180,"RAPID DESENSITIZATION PROC,EACH HOUR",,95180,,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,96105,ASSESSMENT OF APHASIA,,96105,,$460.00 ,$460.00 ,$128.80 ,$420.90 ,$322.00 ,$385.02 ,$420.90 ,$420.90 ,$420.90 ,$169.51 ,$276.00 ,$138.00 ,$414.00 ,$345.00 ,$368.00 ,$381.80
Hoopeston Regional Hlth Center,96450,"CHEMOTHER,CNS,W/LUMBAR PUNCTURE",,96450,,"$1,110.00 ","$1,110.00 ",$310.80 ,"$1,015.65 ",$777.00 ,$929.07 ,"$1,015.65 ","$1,015.65 ","$1,015.65 ",$409.04 ,$666.00 ,$333.00 ,$999.00 ,$832.50 ,$888.00 ,$921.30
Hoopeston Regional Hlth Center,96542,"CHEMOTHER INJECT,SUBARACH/INTRAVENT",,96542,,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,99360,PHYS STANDBY SVC PROLNG PHYS ATTN EA 30 MINUTES,,99360,,$375.00 ,$375.00 ,$105.00 ,$343.13 ,$262.50 ,$313.88 ,$343.13 ,$343.13 ,$343.13 ,$138.19 ,$225.00 ,$112.50 ,$337.50 ,$281.25 ,$300.00 ,$311.25
Hoopeston Regional Hlth Center,99401,"PREVENT COUNSEL,INDIV,15 MIN",,99401,,$99.00 ,$99.00 ,$27.72 ,$90.59 ,$69.30 ,$82.86 ,$90.59 ,$90.59 ,$90.59 ,$36.48 ,$59.40 ,$29.70 ,$89.10 ,$74.25 ,$79.20 ,$82.17
Hoopeston Regional Hlth Center,99404,"PREVENT COUNSEL,INDIV,60 MIN",,99404,,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,99412,"PREVENT COUNSEL,GROUP,60 MIN",,99412,,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,99456,DISABILITY EXAM/OTHER DR,,99456,,$375.00 ,$375.00 ,$105.00 ,$343.13 ,$262.50 ,$313.88 ,$343.13 ,$343.13 ,$343.13 ,$138.19 ,$225.00 ,$112.50 ,$337.50 ,$281.25 ,$300.00 ,$311.25
Hoopeston Regional Hlth Center,D0140,Limit oral eval problm focus,,D0140,,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,90956,ESRD RELATED SVC MONTHLY 2-11 YR OLD 1 VISIT,,90956,,"$1,480.00 ","$1,480.00 ",$414.40 ,"$1,354.20 ","$1,036.00 ","$1,238.76 ","$1,354.20 ","$1,354.20 ","$1,354.20 ",$545.38 ,$888.00 ,$444.00 ,"$1,332.00 ","$1,110.00 ","$1,184.00 ","$1,228.40 "
Hoopeston Regional Hlth Center,84484,"ASSAY OF TROPONIN, QUANT",,84484,,$100.00 ,$100.00 ,$28.00 ,$91.50 ,$70.00 ,$83.70 ,$91.50 ,$91.50 ,$91.50 ,$36.85 ,$60.00 ,$30.00 ,$90.00 ,$75.00 ,$80.00 ,$83.00
Hoopeston Regional Hlth Center,90875,MEDICAL SERVICE,,90875,,$210.00 ,$210.00 ,$58.80 ,$192.15 ,$147.00 ,$175.77 ,$192.15 ,$192.15 ,$192.15 ,$77.39 ,$126.00 ,$63.00 ,$189.00 ,$157.50 ,$168.00 ,$174.30
Hoopeston Regional Hlth Center,90876,MEDICAL SERVICE,,90876,,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,89259,"CRYOPRESERVATION, SPERM",,89259,,$385.00 ,$385.00 ,$107.80 ,$352.28 ,$269.50 ,$322.25 ,$352.28 ,$352.28 ,$352.28 ,$141.87 ,$231.00 ,$115.50 ,$346.50 ,$288.75 ,$308.00 ,$319.55
Hoopeston Regional Hlth Center,89261,"SPERM ISOLATION, COMPLEX",,89261,,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,90865,NARCOSYNTHESIS,,90865,,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,90885,MEDICAL SERVICE,,90885,,$285.00 ,$285.00 ,$79.80 ,$260.78 ,$199.50 ,$238.55 ,$260.78 ,$260.78 ,$260.78 ,$105.02 ,$171.00 ,$85.50 ,$256.50 ,$213.75 ,$228.00 ,$236.55
Hoopeston Regional Hlth Center,G0104,CA screen;flexi sigmoidscope,,G0104,,"$1,090.00 ","$1,090.00 ",$305.20 ,$997.35 ,$763.00 ,$912.33 ,$997.35 ,$997.35 ,$997.35 ,$401.67 ,$654.00 ,$327.00 ,$981.00 ,$817.50 ,$872.00 ,$904.70
Hoopeston Regional Hlth Center,96150,MEDICAL SERVICE,,96150,,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,96151,MEDICAL SERVICE,,96151,,$82.00 ,$82.00 ,$22.96 ,$75.03 ,$57.40 ,$68.63 ,$75.03 ,$75.03 ,$75.03 ,$30.22 ,$49.20 ,$24.60 ,$73.80 ,$61.50 ,$65.60 ,$68.06
Hoopeston Regional Hlth Center,96152,MEDICAL SERVICE,,96152,,$78.00 ,$78.00 ,$21.84 ,$71.37 ,$54.60 ,$65.29 ,$71.37 ,$71.37 ,$71.37 ,$28.74 ,$46.80 ,$23.40 ,$70.20 ,$58.50 ,$62.40 ,$64.74
Hoopeston Regional Hlth Center,96153,MEDICAL SERVICE,,96153,,$25.00 ,$25.00 ,$7.00 ,$22.88 ,$17.50 ,$20.93 ,$22.88 ,$22.88 ,$22.88 ,$9.21 ,$15.00 ,$7.50 ,$22.50 ,$18.75 ,$20.00 ,$20.75
Hoopeston Regional Hlth Center,96154,MEDICAL SERVICE,,96154,,$91.00 ,$91.00 ,$25.48 ,$83.27 ,$63.70 ,$76.17 ,$83.27 ,$83.27 ,$83.27 ,$33.53 ,$54.60 ,$27.30 ,$81.90 ,$68.25 ,$72.80 ,$75.53
Hoopeston Regional Hlth Center,97804,"MED NUTR THER, GROUP, EA 30 MIN",,97804,,$62.00 ,$62.00 ,$17.36 ,$56.73 ,$43.40 ,$51.89 ,$56.73 ,$56.73 ,$56.73 ,$22.85 ,$37.20 ,$18.60 ,$55.80 ,$46.50 ,$49.60 ,$51.46
Hoopeston Regional Hlth Center,77427,"RADIATION,MANGEMENT,5 TX'S",,77427,,"$1,600.00 ","$1,600.00 ",$448.00 ,"$1,464.00 ","$1,120.00 ","$1,339.20 ","$1,464.00 ","$1,464.00 ","$1,464.00 ",$589.60 ,$960.00 ,$480.00 ,"$1,440.00 ","$1,200.00 ","$1,280.00 ","$1,328.00 "
Hoopeston Regional Hlth Center,83880,NATRIURETIC PEPTIDE,,83880,,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,87172,PINWORM EXAM,,87172,,$66.00 ,$66.00 ,$18.48 ,$60.39 ,$46.20 ,$55.24 ,$60.39 ,$60.39 ,$60.39 ,$24.32 ,$39.60 ,$19.80 ,$59.40 ,$49.50 ,$52.80 ,$54.78
Hoopeston Regional Hlth Center,94002,"VENT MANAGEMENT, INPATIENT, INITIAL DAY",,94002,,$820.00 ,$820.00 ,$229.60 ,$750.30 ,$574.00 ,$686.34 ,$750.30 ,$750.30 ,$750.30 ,$302.17 ,$492.00 ,$246.00 ,$738.00 ,$615.00 ,$656.00 ,$680.60
Hoopeston Regional Hlth Center,94003,"VENT MANAGEMENT, INPATIENT, SUBSEQ DAY",,94003,,$485.00 ,$485.00 ,$135.80 ,$443.78 ,$339.50 ,$405.95 ,$443.78 ,$443.78 ,$443.78 ,$178.72 ,$291.00 ,$145.50 ,$436.50 ,$363.75 ,$388.00 ,$402.55
Hoopeston Regional Hlth Center,94004,"VENT MANAGEMENT, NURSING HOME,PER DAY",,94004,,$340.00 ,$340.00 ,$95.20 ,$311.10 ,$238.00 ,$284.58 ,$311.10 ,$311.10 ,$311.10 ,$125.29 ,$204.00 ,$102.00 ,$306.00 ,$255.00 ,$272.00 ,$282.20
Hoopeston Regional Hlth Center,94005,"VENT MANAGEMENT, HOME, > 30 MIN",,94005,,$600.00 ,$600.00 ,$168.00 ,$549.00 ,$420.00 ,$502.20 ,$549.00 ,$549.00 ,$549.00 ,$221.10 ,$360.00 ,$180.00 ,$540.00 ,$450.00 ,$480.00 ,$498.00
Hoopeston Regional Hlth Center,96040,"GENETIC COUNSELING, EACH 30 MIN",,96040,,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,96409,"CHEMOTHER, IV PUSH, SNGL DRUG",,96409,,$510.00 ,$510.00 ,$142.80 ,$466.65 ,$357.00 ,$426.87 ,$466.65 ,$466.65 ,$466.65 ,$187.94 ,$306.00 ,$153.00 ,$459.00 ,$382.50 ,$408.00 ,$423.30
Hoopeston Regional Hlth Center,96411,"CHEMOTHER, IV PUSH,EA ADD DRUG",,96411,,$295.00 ,$295.00 ,$82.60 ,$269.93 ,$206.50 ,$246.92 ,$269.93 ,$269.93 ,$269.93 ,$108.71 ,$177.00 ,$88.50 ,$265.50 ,$221.25 ,$236.00 ,$244.85
Hoopeston Regional Hlth Center,96413,"CHEMOTHER, IV INFUSION, 1 HR",,96413,,$630.00 ,$630.00 ,$176.40 ,$576.45 ,$441.00 ,$527.31 ,$576.45 ,$576.45 ,$576.45 ,$232.16 ,$378.00 ,$189.00 ,$567.00 ,$472.50 ,$504.00 ,$522.90
Hoopeston Regional Hlth Center,96415,"CHEMOTHER, IV INFUSION, EA ADD HR",,96415,,$170.00 ,$170.00 ,$47.60 ,$155.55 ,$119.00 ,$142.29 ,$155.55 ,$155.55 ,$155.55 ,$62.65 ,$102.00 ,$51.00 ,$153.00 ,$127.50 ,$136.00 ,$141.10
Hoopeston Regional Hlth Center,96416,CHEMOTHER PROLONG INFUSE W/PUMP,,96416,,$750.00 ,$750.00 ,$210.00 ,$686.25 ,$525.00 ,$627.75 ,$686.25 ,$686.25 ,$686.25 ,$276.38 ,$450.00 ,$225.00 ,$675.00 ,$562.50 ,$600.00 ,$622.50
Hoopeston Regional Hlth Center,96417,"CHEMOTHER, IV INFUSE, EACH SEQU INFUS",,96417,,$370.00 ,$370.00 ,$103.60 ,$338.55 ,$259.00 ,$309.69 ,$338.55 ,$338.55 ,$338.55 ,$136.35 ,$222.00 ,$111.00 ,$333.00 ,$277.50 ,$296.00 ,$307.10
Hoopeston Regional Hlth Center,96521,"REFILL/MAINT, PORTABLE PUMP",,96521,,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,96522,REFILL/MAINT SYSTEMIC PUMP/RESVR,,96522,,$395.00 ,$395.00 ,$110.60 ,$361.43 ,$276.50 ,$330.62 ,$361.43 ,$361.43 ,$361.43 ,$145.56 ,$237.00 ,$118.50 ,$355.50 ,$296.25 ,$316.00 ,$327.85
Hoopeston Regional Hlth Center,97605,NEGATIVE PRESSURE WOUND THERAPY DME = 50 SQ CM,,97605,,$265.00 ,$265.00 ,$74.20 ,$242.48 ,$185.50 ,$221.81 ,$242.48 ,$242.48 ,$242.48 ,$97.65 ,$159.00 ,$79.50 ,$238.50 ,$198.75 ,$212.00 ,$219.95
Hoopeston Regional Hlth Center,97606,NEGATIVE PRESSURE WOUND THERAPY DME >50 SQ CM,,97606,,$335.00 ,$335.00 ,$93.80 ,$306.53 ,$234.50 ,$280.40 ,$306.53 ,$306.53 ,$306.53 ,$123.45 ,$201.00 ,$100.50 ,$301.50 ,$251.25 ,$268.00 ,$278.05
Hoopeston Regional Hlth Center,97760,ORTHOTICS MGMT & TRAINJ INITIAL ENCTR EA 15 MINS,,97760,,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,99339,"DOMICIL/REST-HOME CARE SUPERVISION, <30 MIN",,99339,,$245.00 ,$245.00 ,$68.60 ,$224.18 ,$171.50 ,$205.07 ,$224.18 ,$224.18 ,$224.18 ,$90.28 ,$147.00 ,$73.50 ,$220.50 ,$183.75 ,$196.00 ,$203.35
Hoopeston Regional Hlth Center,99340,"DOMICIL/REST-HOME CARE SUPERVISION, =>30 MIN",,99340,,$380.00 ,$380.00 ,$106.40 ,$347.70 ,$266.00 ,$318.06 ,$347.70 ,$347.70 ,$347.70 ,$140.03 ,$228.00 ,$114.00 ,$342.00 ,$285.00 ,$304.00 ,$315.40
Hoopeston Regional Hlth Center,89322,"SEMEN ANALYSIS, STRICT MORPHOLOGIC CRITERIA",,89322,,$360.00 ,$360.00 ,$100.80 ,$329.40 ,$252.00 ,$301.32 ,$329.40 ,$329.40 ,$329.40 ,$132.66 ,$216.00 ,$108.00 ,$324.00 ,$270.00 ,$288.00 ,$298.80
Hoopeston Regional Hlth Center,90951,ESRD RELATED SVC MONTHLY & <2 YR OLD 4/> VISITS,,90951,,"$4,140.00 ","$4,140.00 ","$1,159.20 ","$3,788.10 ","$2,898.00 ","$3,465.18 ","$3,788.10 ","$3,788.10 ","$3,788.10 ","$1,525.59 ","$2,484.00 ","$1,242.00 ","$3,726.00 ","$3,105.00 ","$3,312.00 ","$3,436.20 "
Hoopeston Regional Hlth Center,90954,ESRD RELATED SVC MONTHLY 2-11 YR OLD 4/> VISITS,,90954,,"$4,240.00 ","$4,240.00 ","$1,187.20 ","$3,879.60 ","$2,968.00 ","$3,548.88 ","$3,879.60 ","$3,879.60 ","$3,879.60 ","$1,562.44 ","$2,544.00 ","$1,272.00 ","$3,816.00 ","$3,180.00 ","$3,392.00 ","$3,519.20 "
Hoopeston Regional Hlth Center,90955,ESRD RELATED SVC MONTHLY 2-11 YR OLD 2/3 VISITS,,90955,,"$2,020.00 ","$2,020.00 ",$565.60 ,"$1,848.30 ","$1,414.00 ","$1,690.74 ","$1,848.30 ","$1,848.30 ","$1,848.30 ",$744.37 ,"$1,212.00 ",$606.00 ,"$1,818.00 ","$1,515.00 ","$1,616.00 ","$1,676.60 "
Hoopeston Regional Hlth Center,90957,ESRD RELATED SVC MONTHLY 12-19 YR OLD 4/> VISITS,,90957,,"$3,350.00 ","$3,350.00 ",$938.00 ,"$3,065.25 ","$2,345.00 ","$2,803.95 ","$3,065.25 ","$3,065.25 ","$3,065.25 ","$1,234.48 ","$2,010.00 ","$1,005.00 ","$3,015.00 ","$2,512.50 ","$2,680.00 ","$2,780.50 "
Hoopeston Regional Hlth Center,90958,ESRD RELATED SVC MONTHLY 12-19 YR OLD 2/3 VISITS,,90958,,"$2,250.00 ","$2,250.00 ",$630.00 ,"$2,058.75 ","$1,575.00 ","$1,883.25 ","$2,058.75 ","$2,058.75 ","$2,058.75 ",$829.13 ,"$1,350.00 ",$675.00 ,"$2,025.00 ","$1,687.50 ","$1,800.00 ","$1,867.50 "
Hoopeston Regional Hlth Center,90959,ESRD RELATED SVC MONTHLY 12-19 YR OLD 1 VISIT,,90959,,"$1,420.00 ","$1,420.00 ",$397.60 ,"$1,299.30 ",$994.00 ,"$1,188.54 ","$1,299.30 ","$1,299.30 ","$1,299.30 ",$523.27 ,$852.00 ,$426.00 ,"$1,278.00 ","$1,065.00 ","$1,136.00 ","$1,178.60 "
Hoopeston Regional Hlth Center,90960,ESRD RELATED SVC MONTHLY 20&/> YR OLD 4/> VISITS,,90960,,"$1,370.00 ","$1,370.00 ",$383.60 ,"$1,253.55 ",$959.00 ,"$1,146.69 ","$1,253.55 ","$1,253.55 ","$1,253.55 ",$504.85 ,$822.00 ,$411.00 ,"$1,233.00 ","$1,027.50 ","$1,096.00 ","$1,137.10 "
Hoopeston Regional Hlth Center,90961,ESRD RELATED SVC MONTHLY 20/>YR OLD 2/3 VISITS,,90961,,"$1,110.00 ","$1,110.00 ",$310.80 ,"$1,015.65 ",$777.00 ,$929.07 ,"$1,015.65 ","$1,015.65 ","$1,015.65 ",$409.04 ,$666.00 ,$333.00 ,$999.00 ,$832.50 ,$888.00 ,$921.30
Hoopeston Regional Hlth Center,90962,ESRD RELATED SVC MONTHLY 20&/>YR OLD 1 VISIT,,90962,,$900.00 ,$900.00 ,$252.00 ,$823.50 ,$630.00 ,$753.30 ,$823.50 ,$823.50 ,$823.50 ,$331.65 ,$540.00 ,$270.00 ,$810.00 ,$675.00 ,$720.00 ,$747.00
Hoopeston Regional Hlth Center,90963,"ESRD SERVICES, HOME DIALYSIS, PER MONTH, < 2 YR OLD",,90963,,"$2,870.00 ","$2,870.00 ",$803.60 ,"$2,626.05 ","$2,009.00 ","$2,402.19 ","$2,626.05 ","$2,626.05 ","$2,626.05 ","$1,057.60 ","$1,722.00 ",$861.00 ,"$2,583.00 ","$2,152.50 ","$2,296.00 ","$2,382.10 "
Hoopeston Regional Hlth Center,90964,"ESRD SERVICES, HOME DIALYSIS, PER MONTH, 2-11 YR OLD",,90964,,"$2,390.00 ","$2,390.00 ",$669.20 ,"$2,186.85 ","$1,673.00 ","$2,000.43 ","$2,186.85 ","$2,186.85 ","$2,186.85 ",$880.72 ,"$1,434.00 ",$717.00 ,"$2,151.00 ","$1,792.50 ","$1,912.00 ","$1,983.70 "
Hoopeston Regional Hlth Center,90965,"ESRD SERVICES, HOME DIALYSIS, PER MONTH, 12-19 YR OLD",,90965,,"$2,160.00 ","$2,160.00 ",$604.80 ,"$1,976.40 ","$1,512.00 ","$1,807.92 ","$1,976.40 ","$1,976.40 ","$1,976.40 ",$795.96 ,"$1,296.00 ",$648.00 ,"$1,944.00 ","$1,620.00 ","$1,728.00 ","$1,792.80 "
Hoopeston Regional Hlth Center,90966,"ESRD SERVICES, HOME DIALYSIS, PER MONTH, 20+ YR OLD",,90966,,"$1,020.00 ","$1,020.00 ",$285.60 ,$933.30 ,$714.00 ,$853.74 ,$933.30 ,$933.30 ,$933.30 ,$375.87 ,$612.00 ,$306.00 ,$918.00 ,$765.00 ,$816.00 ,$846.60
Hoopeston Regional Hlth Center,90967,"ESRD SERVICES, PER DAY, < 2 YR OLD",,90967,,$115.00 ,$115.00 ,$32.20 ,$105.23 ,$80.50 ,$96.26 ,$105.23 ,$105.23 ,$105.23 ,$42.38 ,$69.00 ,$34.50 ,$103.50 ,$86.25 ,$92.00 ,$95.45
Hoopeston Regional Hlth Center,90968,"ESRD SERVICES, PER DAY, 2-11 YR OLD",,90968,,$88.00 ,$88.00 ,$24.64 ,$80.52 ,$61.60 ,$73.66 ,$80.52 ,$80.52 ,$80.52 ,$32.43 ,$52.80 ,$26.40 ,$79.20 ,$66.00 ,$70.40 ,$73.04
Hoopeston Regional Hlth Center,90969,"ESRD SERVICES, PER DAY, 12-19 YR OLD",,90969,,$79.00 ,$79.00 ,$22.12 ,$72.29 ,$55.30 ,$66.12 ,$72.29 ,$72.29 ,$72.29 ,$29.11 ,$47.40 ,$23.70 ,$71.10 ,$59.25 ,$63.20 ,$65.57
Hoopeston Regional Hlth Center,90970,"ESRD SERVICES, PER DAY,20+ YR OLD",,90970,,$44.00 ,$44.00 ,$12.32 ,$40.26 ,$30.80 ,$36.83 ,$40.26 ,$40.26 ,$40.26 ,$16.21 ,$26.40 ,$13.20 ,$39.60 ,$33.00 ,$35.20 ,$36.52
Hoopeston Regional Hlth Center,96125,MEDICAL SERVICE,,96125,,$730.00 ,$730.00 ,$204.40 ,$667.95 ,$511.00 ,$611.01 ,$667.95 ,$667.95 ,$667.95 ,$269.01 ,$438.00 ,$219.00 ,$657.00 ,$547.50 ,$584.00 ,$605.90
Hoopeston Regional Hlth Center,96367,IV INFUSION THER PROPH ADDL SEQUENTIAL TO 1 HR,,96367,,$180.00 ,$180.00 ,$50.40 ,$164.70 ,$126.00 ,$150.66 ,$164.70 ,$164.70 ,$164.70 ,$66.33 ,$108.00 ,$54.00 ,$162.00 ,$135.00 ,$144.00 ,$149.40
Hoopeston Regional Hlth Center,96368,"IV INFUSION, THERAP/PROPH/DIAGNOST,CONCURRENT INFUSION",,96368,,$130.00 ,$130.00 ,$36.40 ,$118.95 ,$91.00 ,$108.81 ,$118.95 ,$118.95 ,$118.95 ,$47.91 ,$78.00 ,$39.00 ,$117.00 ,$97.50 ,$104.00 ,$107.90
Hoopeston Regional Hlth Center,96369,"SUBCUT INFUSION, THERAP/PROPH/DIAGNOST,INITIAL,1ST HOUR",,96369,,$780.00 ,$780.00 ,$218.40 ,$713.70 ,$546.00 ,$652.86 ,$713.70 ,$713.70 ,$713.70 ,$287.43 ,$468.00 ,$234.00 ,$702.00 ,$585.00 ,$624.00 ,$647.40
Hoopeston Regional Hlth Center,96370,"SUBCUT INFUSION, THERAP/PROPH/DIAGNOST,EA ADD HOUR",,96370,,$105.00 ,$105.00 ,$29.40 ,$96.08 ,$73.50 ,$87.89 ,$96.08 ,$96.08 ,$96.08 ,$38.69 ,$63.00 ,$31.50 ,$94.50 ,$78.75 ,$84.00 ,$87.15
Hoopeston Regional Hlth Center,96371,"SUBCUT INFUSION, THERAP/PROPH/DIAGNOST,ADD PUMP SET",,96371,,$390.00 ,$390.00 ,$109.20 ,$356.85 ,$273.00 ,$326.43 ,$356.85 ,$356.85 ,$356.85 ,$143.72 ,$234.00 ,$117.00 ,$351.00 ,$292.50 ,$312.00 ,$323.70
Hoopeston Regional Hlth Center,99366,TEAM CONFERENCE FACE-TO-FACE NONPHYSICIAN,,99366,,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,99367,TEAM CONFERENCE NON-FACE-TO-FACE PHYSICIAN,,99367,,$250.00 ,$250.00 ,$70.00 ,$228.75 ,$175.00 ,$209.25 ,$228.75 ,$228.75 ,$228.75 ,$92.13 ,$150.00 ,$75.00 ,$225.00 ,$187.50 ,$200.00 ,$207.50
Hoopeston Regional Hlth Center,99368,TEAM CONFERENCE NON-FACE-TO-FACE NONPHYSICIAN,,99368,,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,99409,ALCOHOL/SUBSTANCE SCREEN & INTERVEN >30 MIN,,99409,,$260.00 ,$260.00 ,$72.80 ,$237.90 ,$182.00 ,$217.62 ,$237.90 ,$237.90 ,$237.90 ,$95.81 ,$156.00 ,$78.00 ,$234.00 ,$195.00 ,$208.00 ,$215.80
Hoopeston Regional Hlth Center,99469,"SUBSEQUENT HOSP NEONATE 28 DAY OR LESS, CRITICALLY ILL",,99469,,"$2,660.00 ","$2,660.00 ",$744.80 ,"$2,433.90 ","$1,862.00 ","$2,226.42 ","$2,433.90 ","$2,433.90 ","$2,433.90 ",$980.21 ,"$1,596.00 ",$798.00 ,"$2,394.00 ","$1,995.00 ","$2,128.00 ","$2,207.80 "
Hoopeston Regional Hlth Center,99471,INITIAL PED CRITICAL CARE 29 DAY THRU 24 MO,,99471,,"$3,760.00 ","$3,760.00 ","$1,052.80 ","$3,440.40 ","$2,632.00 ","$3,147.12 ","$3,440.40 ","$3,440.40 ","$3,440.40 ","$1,385.56 ","$2,256.00 ","$1,128.00 ","$3,384.00 ","$2,820.00 ","$3,008.00 ","$3,120.80 "
Hoopeston Regional Hlth Center,99472,SUBSEQUENT PED CRITICAL CARE 29 DAY THRU 24 MO,,99472,,"$2,630.00 ","$2,630.00 ",$736.40 ,"$2,406.45 ","$1,841.00 ","$2,201.31 ","$2,406.45 ","$2,406.45 ","$2,406.45 ",$969.16 ,"$1,578.00 ",$789.00 ,"$2,367.00 ","$1,972.50 ","$2,104.00 ","$2,182.90 "
Hoopeston Regional Hlth Center,99475,INITIAL PED CRITICAL CARE 2 YR THRU 5 YR,,99475,,"$3,110.00 ","$3,110.00 ",$870.80 ,"$2,845.65 ","$2,177.00 ","$2,603.07 ","$2,845.65 ","$2,845.65 ","$2,845.65 ","$1,146.04 ","$1,866.00 ",$933.00 ,"$2,799.00 ","$2,332.50 ","$2,488.00 ","$2,581.30 "
Hoopeston Regional Hlth Center,99476,SUBSEQUENT PED CRITICAL CARE 2 YR THRU 5 YR,,99476,,"$2,110.00 ","$2,110.00 ",$590.80 ,"$1,930.65 ","$1,477.00 ","$1,766.07 ","$1,930.65 ","$1,930.65 ","$1,930.65 ",$777.54 ,"$1,266.00 ",$633.00 ,"$1,899.00 ","$1,582.50 ","$1,688.00 ","$1,751.30 "
Hoopeston Regional Hlth Center,99477,"INITIAL HOSP NEONATE 28 DAY OR LESS, NOT CRITICALLY ILL",,99477,,"$2,410.00 ","$2,410.00 ",$674.80 ,"$2,205.15 ","$1,687.00 ","$2,017.17 ","$2,205.15 ","$2,205.15 ","$2,205.15 ",$888.09 ,"$1,446.00 ",$723.00 ,"$2,169.00 ","$1,807.50 ","$1,928.00 ","$2,000.30 "
Hoopeston Regional Hlth Center,99478,SUBSEQUENT INTENSIVE CARE INFANT < 1500 GRAMS,,99478,,"$1,100.00 ","$1,100.00 ",$308.00 ,"$1,006.50 ",$770.00 ,$920.70 ,"$1,006.50 ","$1,006.50 ","$1,006.50 ",$405.35 ,$660.00 ,$330.00 ,$990.00 ,$825.00 ,$880.00 ,$913.00
Hoopeston Regional Hlth Center,99479,SUBSEQUENT INTENSIVE CARE INFANT 1500-2500 GRAMS,,99479,,"$1,030.00 ","$1,030.00 ",$288.40 ,$942.45 ,$721.00 ,$862.11 ,$942.45 ,$942.45 ,$942.45 ,$379.56 ,$618.00 ,$309.00 ,$927.00 ,$772.50 ,$824.00 ,$854.90
Hoopeston Regional Hlth Center,99480,SUBSEQUENT INTENSIVE CARE INFANT 2501-5000 GRAMS,,99480,,$970.00 ,$970.00 ,$271.60 ,$887.55 ,$679.00 ,$811.89 ,$887.55 ,$887.55 ,$887.55 ,$357.45 ,$582.00 ,$291.00 ,$873.00 ,$727.50 ,$776.00 ,$805.10
Hoopeston Regional Hlth Center,1157F,ADVANCE CARE PLAN OR EQUIV PRESENT IN MEDICAL RECORD,,1157F,,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.01 ,$0.00 ,$0.01 ,$0.00 ,$0.01 ,$0.01 ,$0.01 ,$0.01
Hoopeston Regional Hlth Center,D1206,Topical fluoride varnish,,D1206,,$45.00 ,$45.00 ,$12.60 ,$41.18 ,$31.50 ,$37.67 ,$41.18 ,$41.18 ,$41.18 ,$16.58 ,$27.00 ,$13.50 ,$40.50 ,$33.75 ,$36.00 ,$37.35
Hoopeston Regional Hlth Center,G0396,Alcohol/subs interv 15-30mn,,G0396,,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,G0397,Alcohol/subs interv >30 min,,G0397,,$240.00 ,$240.00 ,$67.20 ,$219.60 ,$168.00 ,$200.88 ,$219.60 ,$219.60 ,$219.60 ,$88.44 ,$144.00 ,$72.00 ,$216.00 ,$180.00 ,$192.00 ,$199.20
Hoopeston Regional Hlth Center,G0406,Inpt/tele Follow Up 15,,G0406,,$185.00 ,$185.00 ,$51.80 ,$169.28 ,$129.50 ,$154.85 ,$169.28 ,$169.28 ,$169.28 ,$68.17 ,$111.00 ,$55.50 ,$166.50 ,$138.75 ,$148.00 ,$153.55
Hoopeston Regional Hlth Center,G0407,Inpt/tele Follow Up 25,,G0407,,$305.00 ,$305.00 ,$85.40 ,$279.08 ,$213.50 ,$255.29 ,$279.08 ,$279.08 ,$279.08 ,$112.39 ,$183.00 ,$91.50 ,$274.50 ,$228.75 ,$244.00 ,$253.15
Hoopeston Regional Hlth Center,G0408,Inpt/tele Follow Up 35,,G0408,,$430.00 ,$430.00 ,$120.40 ,$393.45 ,$301.00 ,$359.91 ,$393.45 ,$393.45 ,$393.45 ,$158.46 ,$258.00 ,$129.00 ,$387.00 ,$322.50 ,$344.00 ,$356.90
Hoopeston Regional Hlth Center,G0420,Ed svc CKD ind per session,,G0420,,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,G0421,Ed svc CKD grp per session,,G0421,,$68.00 ,$68.00 ,$19.04 ,$62.22 ,$47.60 ,$56.92 ,$62.22 ,$62.22 ,$62.22 ,$25.06 ,$40.80 ,$20.40 ,$61.20 ,$51.00 ,$54.40 ,$56.44
Hoopeston Regional Hlth Center,G0425,Inpt/ed Teleconsult30,,G0425,,$445.00 ,$445.00 ,$124.60 ,$407.18 ,$311.50 ,$372.47 ,$407.18 ,$407.18 ,$407.18 ,$163.98 ,$267.00 ,$133.50 ,$400.50 ,$333.75 ,$356.00 ,$369.35
Hoopeston Regional Hlth Center,G0426,Inpt/ed Teleconsult50,,G0426,,$580.00 ,$580.00 ,$162.40 ,$530.70 ,$406.00 ,$485.46 ,$530.70 ,$530.70 ,$530.70 ,$213.73 ,$348.00 ,$174.00 ,$522.00 ,$435.00 ,$464.00 ,$481.40
Hoopeston Regional Hlth Center,G0427,Inpt/ed Teleconsult70,,G0427,,$870.00 ,$870.00 ,$243.60 ,$796.05 ,$609.00 ,$728.19 ,$796.05 ,$796.05 ,$796.05 ,$320.60 ,$522.00 ,$261.00 ,$783.00 ,$652.50 ,$696.00 ,$722.10
Hoopeston Regional Hlth Center,7090616,Cosmetic Consultation,,0,,$75.00 ,$75.00 ,$21.00 ,$68.63 ,$52.50 ,$62.78 ,$68.63 ,$68.63 ,$68.63 ,$27.64 ,$45.00 ,$22.50 ,$67.50 ,$56.25 ,$60.00 ,$62.25
Hoopeston Regional Hlth Center,7551117,Fiducial Markers 1 Pack,,A4648,,$356.00 ,$356.00 ,$99.68 ,$325.74 ,$249.20 ,$297.97 ,$325.74 ,$325.74 ,$325.74 ,$131.19 ,$213.60 ,$106.80 ,$320.40 ,$267.00 ,$284.80 ,$295.48
Hoopeston Regional Hlth Center,7551118,Fiducial Marker 3 Pack,,A4648,,$675.00 ,$675.00 ,$189.00 ,$617.63 ,$472.50 ,$564.98 ,$617.63 ,$617.63 ,$617.63 ,$248.74 ,$405.00 ,$202.50 ,$607.50 ,$506.25 ,$540.00 ,$560.25
Hoopeston Regional Hlth Center,7999916,Pr Ime Eval And Report,,99456,,$840.00 ,$840.00 ,$235.20 ,$768.60 ,$588.00 ,$703.08 ,$768.60 ,$768.60 ,$768.60 ,$309.54 ,$504.00 ,$252.00 ,$756.00 ,$630.00 ,$672.00 ,$697.20
Hoopeston Regional Hlth Center,7999917,Pr Psych Ime Rcrd Rvw Per Hr,,90885,,$200.00 ,$200.00 ,$56.00 ,$183.00 ,$140.00 ,$167.40 ,$183.00 ,$183.00 ,$183.00 ,$73.70 ,$120.00 ,$60.00 ,$180.00 ,$150.00 ,$160.00 ,$166.00
Hoopeston Regional Hlth Center,84112,EVAL C/V AMNIOTIC FLUID PROTEIN QUAL EA SPECIMEN,,84112,,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,90867,REPET TMS TX INITIAL W/MAP/MOTR THRESHLD/DEL&MNG,,90867,,"$1,050.00 ","$1,050.00 ",$294.00 ,$960.75 ,$735.00 ,$878.85 ,$960.75 ,$960.75 ,$960.75 ,$386.93 ,$630.00 ,$315.00 ,$945.00 ,$787.50 ,$840.00 ,$871.50
Hoopeston Regional Hlth Center,90868,THERAP REPETITIVE TMS TX SUBSEQ DELIVERY & MNGT,,90868,,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,96446,"CHEMOTHERAPY, PERITONEAL CAVITY VIA INDWELLING PORT/CATHETER",,96446,,$910.00 ,$910.00 ,$254.80 ,$832.65 ,$637.00 ,$761.67 ,$832.65 ,$832.65 ,$832.65 ,$335.34 ,$546.00 ,$273.00 ,$819.00 ,$682.50 ,$728.00 ,$755.30
Hoopeston Regional Hlth Center,0212T,"COMPREHENSIVE AUDIOMETRY THRESHOLD AND SPEECH RECOGNITION, AUTOMATED",,0212T,,$275.00 ,$275.00 ,$77.00 ,$251.63 ,$192.50 ,$230.18 ,$251.63 ,$251.63 ,$251.63 ,$101.34 ,$165.00 ,$82.50 ,$247.50 ,$206.25 ,$220.00 ,$228.25
Hoopeston Regional Hlth Center,G0445,High inten beh couns STD 30m,,G0445,,$74.00 ,$74.00 ,$20.72 ,$67.71 ,$51.80 ,$61.94 ,$67.71 ,$67.71 ,$67.71 ,$27.27 ,$44.40 ,$22.20 ,$66.60 ,$55.50 ,$59.20 ,$61.42
Hoopeston Regional Hlth Center,32554,THORACENTESIS NEEDLE/CATH PLEURA W/O IMAGING,,32554,,"$5,940.00 ","$5,940.00 ","$1,663.20 ","$5,435.10 ","$4,158.00 ","$4,971.78 ","$5,435.10 ","$5,435.10 ","$5,435.10 ","$2,188.89 ","$3,564.00 ","$1,782.00 ","$5,346.00 ","$4,455.00 ","$4,752.00 ","$4,930.20 "
Hoopeston Regional Hlth Center,32555,THORACENTESIS NEEDLE/CATH PLEURA W/IMAGING,,32555,,"$3,820.00 ","$3,820.00 ","$1,069.60 ","$3,495.30 ","$2,674.00 ","$3,197.34 ","$3,495.30 ","$3,495.30 ","$3,495.30 ","$1,407.67 ","$2,292.00 ","$1,146.00 ","$3,438.00 ","$2,865.00 ","$3,056.00 ","$3,170.60 "
Hoopeston Regional Hlth Center,32556,PERQ DRAINAGE PLEURA INSERT CATH W/O IMAGING,,32556,,"$4,180.00 ","$4,180.00 ","$1,170.40 ","$3,824.70 ","$2,926.00 ","$3,498.66 ","$3,824.70 ","$3,824.70 ","$3,824.70 ","$1,540.33 ","$2,508.00 ","$1,254.00 ","$3,762.00 ","$3,135.00 ","$3,344.00 ","$3,469.40 "
Hoopeston Regional Hlth Center,32557,PERQ DRAINAGE PLEURA INSERT CATH W/IMAGING,,32557,,"$7,390.00 ","$7,390.00 ","$2,069.20 ","$6,761.85 ","$5,173.00 ","$6,185.43 ","$6,761.85 ","$6,761.85 ","$6,761.85 ","$2,723.22 ","$4,434.00 ","$2,217.00 ","$6,651.00 ","$5,542.50 ","$5,912.00 ","$6,133.70 "
Hoopeston Regional Hlth Center,95907,MOTOR &/SENS 1-2 NRV CNDJ PRECONF ELTRODE LIMB,,95907,,$700.00 ,$700.00 ,$196.00 ,$640.50 ,$490.00 ,$585.90 ,$640.50 ,$640.50 ,$640.50 ,$257.95 ,$420.00 ,$210.00 ,$630.00 ,$525.00 ,$560.00 ,$581.00
Hoopeston Regional Hlth Center,95908,MOTOR &/SENS 3-4 NRV CNDJ PRECONF ELTRODE LIMB,,95908,,$850.00 ,$850.00 ,$238.00 ,$777.75 ,$595.00 ,$711.45 ,$777.75 ,$777.75 ,$777.75 ,$313.23 ,$510.00 ,$255.00 ,$765.00 ,$637.50 ,$680.00 ,$705.50
Hoopeston Regional Hlth Center,95909,MOTOR &/SENS 5-6 NRV CNDJ PRECONF ELTRODE LIMB,,95909,,"$1,010.00 ","$1,010.00 ",$282.80 ,$924.15 ,$707.00 ,$845.37 ,$924.15 ,$924.15 ,$924.15 ,$372.19 ,$606.00 ,$303.00 ,$909.00 ,$757.50 ,$808.00 ,$838.30
Hoopeston Regional Hlth Center,95910,MOTOR &/SENS 7-8 NRV CNDJ PRECONF ELTRODE LIMB,,95910,,"$1,410.00 ","$1,410.00 ",$394.80 ,"$1,290.15 ",$987.00 ,"$1,180.17 ","$1,290.15 ","$1,290.15 ","$1,290.15 ",$519.59 ,$846.00 ,$423.00 ,"$1,269.00 ","$1,057.50 ","$1,128.00 ","$1,170.30 "
Hoopeston Regional Hlth Center,95911,MOTOR &/SENS 9-10 NRV CNDJ PRECONF ELTRODE LIMB,,95911,,"$1,630.00 ","$1,630.00 ",$456.40 ,"$1,491.45 ","$1,141.00 ","$1,364.31 ","$1,491.45 ","$1,491.45 ","$1,491.45 ",$600.66 ,$978.00 ,$489.00 ,"$1,467.00 ","$1,222.50 ","$1,304.00 ","$1,352.90 "
Hoopeston Regional Hlth Center,95912,MOTOR &/SENS 11-12 NRV CNDJ PRECONF ELTRODE LIMB,,95912,,"$2,090.00 ","$2,090.00 ",$585.20 ,"$1,912.35 ","$1,463.00 ","$1,749.33 ","$1,912.35 ","$1,912.35 ","$1,912.35 ",$770.17 ,"$1,254.00 ",$627.00 ,"$1,881.00 ","$1,567.50 ","$1,672.00 ","$1,734.70 "
Hoopeston Regional Hlth Center,95913,MOTOR &/SENS 13/> NRV CNDJ PRECONF ELTRODE LIMB,,95913,,"$2,240.00 ","$2,240.00 ",$627.20 ,"$2,049.60 ","$1,568.00 ","$1,874.88 ","$2,049.60 ","$2,049.60 ","$2,049.60 ",$825.44 ,"$1,344.00 ",$672.00 ,"$2,016.00 ","$1,680.00 ","$1,792.00 ","$1,859.20 "
Hoopeston Regional Hlth Center,10035,PERQ SFT TISS LOC DEVICE PLMT 1ST LES W/GDNCE,,10035,,"$2,050.00 ","$2,050.00 ",$574.00 ,"$1,875.75 ","$1,435.00 ","$1,715.85 ","$1,875.75 ","$1,875.75 ","$1,875.75 ",$755.43 ,"$1,230.00 ",$615.00 ,"$1,845.00 ","$1,537.50 ","$1,640.00 ","$1,701.50 "
Hoopeston Regional Hlth Center,10036,PERQ SFT TISS LOC DEVICE PLMT ADD LES W/GDNCE,,10036,,"$1,790.00 ","$1,790.00 ",$501.20 ,"$1,637.85 ","$1,253.00 ","$1,498.23 ","$1,637.85 ","$1,637.85 ","$1,637.85 ",$659.62 ,"$1,074.00 ",$537.00 ,"$1,611.00 ","$1,342.50 ","$1,432.00 ","$1,485.70 "
Hoopeston Regional Hlth Center,99177,INSTRUMENT BASED OCULAR SCR BI W/ONSITE ANALYSIS,,99177,,$80.00 ,$80.00 ,$22.40 ,$73.20 ,$56.00 ,$66.96 ,$73.20 ,$73.20 ,$73.20 ,$29.48 ,$48.00 ,$24.00 ,$72.00 ,$60.00 ,$64.00 ,$66.40
Hoopeston Regional Hlth Center,99415,PROLONGED CLINICAL STAFF SVC OFFICE/O/P 1ST HR,,99415,,$110.00 ,$110.00 ,$30.80 ,$100.65 ,$77.00 ,$92.07 ,$100.65 ,$100.65 ,$100.65 ,$40.54 ,$66.00 ,$33.00 ,$99.00 ,$82.50 ,$88.00 ,$91.30
Hoopeston Regional Hlth Center,99416,PROLONGED CLINICAL STAFF SVC OFFICE/O/P EA ADDL,,99416,,$70.00 ,$70.00 ,$19.60 ,$64.05 ,$49.00 ,$58.59 ,$64.05 ,$64.05 ,$64.05 ,$25.80 ,$42.00 ,$21.00 ,$63.00 ,$52.50 ,$56.00 ,$58.10
Hoopeston Regional Hlth Center,27197,CLSD TX PELVIC RING FX W/O MANIPULATION,,27197,,$800.00 ,$800.00 ,$224.00 ,$732.00 ,$560.00 ,$669.60 ,$732.00 ,$732.00 ,$732.00 ,$294.80 ,$480.00 ,$240.00 ,$720.00 ,$600.00 ,$640.00 ,$664.00
Hoopeston Regional Hlth Center,99152,MOD SED SAME PHYS/QHP INITIAL 15 MINS 5/> YRS,,99152,,$280.00 ,$280.00 ,$78.40 ,$256.20 ,$196.00 ,$234.36 ,$256.20 ,$256.20 ,$256.20 ,$103.18 ,$168.00 ,$84.00 ,$252.00 ,$210.00 ,$224.00 ,$232.40
Hoopeston Regional Hlth Center,99153,MOD SED SAME PHYS/QHP EACH ADDL 15 MINS,,99153,,$120.00 ,$120.00 ,$33.60 ,$109.80 ,$84.00 ,$100.44 ,$109.80 ,$109.80 ,$109.80 ,$44.22 ,$72.00 ,$36.00 ,$108.00 ,$90.00 ,$96.00 ,$99.60
Hoopeston Regional Hlth Center,G0500,Mod sedat endo service >5yrs,,G0500,,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,7099199,Pr Repeat Form Completion,,99199,,$11.00 ,$11.00 ,$3.08 ,$10.07 ,$7.70 ,$9.21 ,$10.07 ,$10.07 ,$10.07 ,$4.05 ,$6.60 ,$3.30 ,$9.90 ,$8.25 ,$8.80 ,$9.13
Hoopeston Regional Hlth Center,G0513,"Prolong prev svcs, first 30m",,G0513,,$530.00 ,$530.00 ,$148.40 ,$484.95 ,$371.00 ,$443.61 ,$484.95 ,$484.95 ,$484.95 ,$195.31 ,$318.00 ,$159.00 ,$477.00 ,$397.50 ,$424.00 ,$439.90
Hoopeston Regional Hlth Center,G0514,"Prolong prev svcs, addl 30m",,G0514,,$315.00 ,$315.00 ,$88.20 ,$288.23 ,$220.50 ,$263.66 ,$288.23 ,$288.23 ,$288.23 ,$116.08 ,$189.00 ,$94.50 ,$283.50 ,$236.25 ,$252.00 ,$261.45
Hoopeston Regional Hlth Center,97763,ORTHOTICS/PROSTH MGMT &/TRAINJ SBSQ ENCTR 15 MIN,,97763,,$155.00 ,$155.00 ,$43.40 ,$141.83 ,$108.50 ,$129.74 ,$141.83 ,$141.83 ,$141.83 ,$57.12 ,$93.00 ,$46.50 ,$139.50 ,$116.25 ,$124.00 ,$128.65
Hoopeston Regional Hlth Center,99483,ASSMT & CARE PLANNING PT W/COGNITIVE IMPAIRMENT,,99483,,$670.00 ,$670.00 ,$187.60 ,$613.05 ,$469.00 ,$560.79 ,$613.05 ,$613.05 ,$613.05 ,$246.90 ,$402.00 ,$201.00 ,$603.00 ,$502.50 ,$536.00 ,$556.10
Hoopeston Regional Hlth Center,10030,IMAGE-GUIDED CATHETER FLUID COLLECTION DRAINAGE,,10030,,"$2,750.00 ","$2,750.00 ",$770.00 ,"$2,516.25 ","$1,925.00 ","$2,301.75 ","$2,516.25 ","$2,516.25 ","$2,516.25 ","$1,013.38 ","$1,650.00 ",$825.00 ,"$2,475.00 ","$2,062.50 ","$2,200.00 ","$2,282.50 "
Hoopeston Regional Hlth Center,19081,BX BREAST W DEVICE 1ST LESION STEREOTACTIC GUIDE,,19081,,"$3,300.00 ","$3,300.00 ",$924.00 ,"$3,019.50 ","$2,310.00 ","$2,762.10 ","$3,019.50 ","$3,019.50 ","$3,019.50 ","$1,216.05 ","$1,980.00 ",$990.00 ,"$2,970.00 ","$2,475.00 ","$2,640.00 ","$2,739.00 "
Hoopeston Regional Hlth Center,19082,BX BREAST W DEVICE ADDL LESION STEREOTACT GUIDE,,19082,,"$2,630.00 ","$2,630.00 ",$736.40 ,"$2,406.45 ","$1,841.00 ","$2,201.31 ","$2,406.45 ","$2,406.45 ","$2,406.45 ",$969.16 ,"$1,578.00 ",$789.00 ,"$2,367.00 ","$1,972.50 ","$2,104.00 ","$2,182.90 "
Hoopeston Regional Hlth Center,19083,BX BREAST W DEVICE 1ST LESION ULTRASOUND GUIDE,,19083,,"$3,270.00 ","$3,270.00 ",$915.60 ,"$2,992.05 ","$2,289.00 ","$2,736.99 ","$2,992.05 ","$2,992.05 ","$2,992.05 ","$1,205.00 ","$1,962.00 ",$981.00 ,"$2,943.00 ","$2,452.50 ","$2,616.00 ","$2,714.10 "
Hoopeston Regional Hlth Center,19084,BX BREAST W DEVICE ADDL LESION ULTRASOUND GUIDE,,19084,,"$2,590.00 ","$2,590.00 ",$725.20 ,"$2,369.85 ","$1,813.00 ","$2,167.83 ","$2,369.85 ","$2,369.85 ","$2,369.85 ",$954.42 ,"$1,554.00 ",$777.00 ,"$2,331.00 ","$1,942.50 ","$2,072.00 ","$2,149.70 "
Hoopeston Regional Hlth Center,19085,BX BREAST W DEVICE 1ST LESION MAGNETIC RES GUIDE,,19085,,"$4,920.00 ","$4,920.00 ","$1,377.60 ","$4,501.80 ","$3,444.00 ","$4,118.04 ","$4,501.80 ","$4,501.80 ","$4,501.80 ","$1,813.02 ","$2,952.00 ","$1,476.00 ","$4,428.00 ","$3,690.00 ","$3,936.00 ","$4,083.60 "
Hoopeston Regional Hlth Center,19086,BX BREAST W DEVICE ADDL LESION MAGNET RES GUIDE,,19086,,"$3,870.00 ","$3,870.00 ","$1,083.60 ","$3,541.05 ","$2,709.00 ","$3,239.19 ","$3,541.05 ","$3,541.05 ","$3,541.05 ","$1,426.10 ","$2,322.00 ","$1,161.00 ","$3,483.00 ","$2,902.50 ","$3,096.00 ","$3,212.10 "
Hoopeston Regional Hlth Center,19281,PERQ DEVICE PLACEMT BREAST LOC 1ST LES W GUIDNCE,,19281,,"$1,290.00 ","$1,290.00 ",$361.20 ,"$1,180.35 ",$903.00 ,"$1,079.73 ","$1,180.35 ","$1,180.35 ","$1,180.35 ",$475.37 ,$774.00 ,$387.00 ,"$1,161.00 ",$967.50 ,"$1,032.00 ","$1,070.70 "
Hoopeston Regional Hlth Center,19282,PERQ DEVICE PLACEMT BREAST LOC EA LES W GUIDNCE,,19282,,$880.00 ,$880.00 ,$246.40 ,$805.20 ,$616.00 ,$736.56 ,$805.20 ,$805.20 ,$805.20 ,$324.28 ,$528.00 ,$264.00 ,$792.00 ,$660.00 ,$704.00 ,$730.40
Hoopeston Regional Hlth Center,19283,PERQ BREAST LOC DEVICE PLACEMT 1ST STRTCTC GUID,,19283,,"$1,450.00 ","$1,450.00 ",$406.00 ,"$1,326.75 ","$1,015.00 ","$1,213.65 ","$1,326.75 ","$1,326.75 ","$1,326.75 ",$534.33 ,$870.00 ,$435.00 ,"$1,305.00 ","$1,087.50 ","$1,160.00 ","$1,203.50 "
Hoopeston Regional Hlth Center,19284,PERQ BREAST LOC DEVICE PLACEMT EA LESION STRTCTC,,19284,,"$1,020.00 ","$1,020.00 ",$285.60 ,$933.30 ,$714.00 ,$853.74 ,$933.30 ,$933.30 ,$933.30 ,$375.87 ,$612.00 ,$306.00 ,$918.00 ,$765.00 ,$816.00 ,$846.60
Hoopeston Regional Hlth Center,19285,PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO US IMAG,,19285,,"$2,330.00 ","$2,330.00 ",$652.40 ,"$2,131.95 ","$1,631.00 ","$1,950.21 ","$2,131.95 ","$2,131.95 ","$2,131.95 ",$858.61 ,"$1,398.00 ",$699.00 ,"$2,097.00 ","$1,747.50 ","$1,864.00 ","$1,933.90 "
Hoopeston Regional Hlth Center,19286,PERQ BREAST LOC DEVICE PLACEMT EACH LES US IMAGE,,19286,,"$1,950.00 ","$1,950.00 ",$546.00 ,"$1,784.25 ","$1,365.00 ","$1,632.15 ","$1,784.25 ","$1,784.25 ","$1,784.25 ",$718.58 ,"$1,170.00 ",$585.00 ,"$1,755.00 ","$1,462.50 ","$1,560.00 ","$1,618.50 "
Hoopeston Regional Hlth Center,19287,PERQ BREAST LOC DEVICE PLACEMT 1ST LESIO MR GUID,,19287,,"$4,330.00 ","$4,330.00 ","$1,212.40 ","$3,961.95 ","$3,031.00 ","$3,624.21 ","$3,961.95 ","$3,961.95 ","$3,961.95 ","$1,595.61 ","$2,598.00 ","$1,299.00 ","$3,897.00 ","$3,247.50 ","$3,464.00 ","$3,593.90 "
Hoopeston Regional Hlth Center,19288,PERQ BREAST LOC DEVICE PLACEMT ADD LESIO MR GUID,,19288,,"$3,410.00 ","$3,410.00 ",$954.80 ,"$3,120.15 ","$2,387.00 ","$2,854.17 ","$3,120.15 ","$3,120.15 ","$3,120.15 ","$1,256.59 ","$2,046.00 ","$1,023.00 ","$3,069.00 ","$2,557.50 ","$2,728.00 ","$2,830.30 "
Hoopeston Regional Hlth Center,99446,INTERPROF PHONE/INTERNET ASSESS/MANAGE 5-10,,99446,,$71.00 ,$71.00 ,$19.88 ,$64.97 ,$49.70 ,$59.43 ,$64.97 ,$64.97 ,$64.97 ,$26.16 ,$42.60 ,$21.30 ,$63.90 ,$53.25 ,$56.80 ,$58.93
Hoopeston Regional Hlth Center,99447,INTERPROF PHONE/INTERNET ASSESS/MANAGE 11-20,,99447,,$150.00 ,$150.00 ,$42.00 ,$137.25 ,$105.00 ,$125.55 ,$137.25 ,$137.25 ,$137.25 ,$55.28 ,$90.00 ,$45.00 ,$135.00 ,$112.50 ,$120.00 ,$124.50
Hoopeston Regional Hlth Center,99448,INTERPROF PHONE/INTERNET ASSESS/MANAGE 21-30,,99448,,$220.00 ,$220.00 ,$61.60 ,$201.30 ,$154.00 ,$184.14 ,$201.30 ,$201.30 ,$201.30 ,$81.07 ,$132.00 ,$66.00 ,$198.00 ,$165.00 ,$176.00 ,$182.60
Hoopeston Regional Hlth Center,99449,INTERPROF PHONE/INTERNET ASSESS/MANAGE31/>,,99449,,$465.00 ,$465.00 ,$130.20 ,$425.48 ,$325.50 ,$389.21 ,$425.48 ,$425.48 ,$425.48 ,$171.35 ,$279.00 ,$139.50 ,$418.50 ,$348.75 ,$372.00 ,$385.95
Table 2: Payer Negotiated Rates,,,,,,,,,,,,,,,,,,,,,
ContractName,CodeType,Code,Description,Service Description,Base Rate Methodology,Negotiated Charge / Base Rate,ServiceCode,Deidentified Minimum,Deidentified Maximum,,,,,,,,,,,,
Aetna Commercial,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$462,611.20 ",IP,"4,660.01","462,611.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,Medical/Surgical,Relative Weights,"$239,521.60 ",IP,"4,660.01","239,521.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$305,688.00 ",IP,"4,660.01","305,688.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$190,760.00 ",IP,"4,660.01","190,760.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-005,LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,Medical/Surgical,Relative Weights,"$163,760.00 ",IP,"4,660.01","163,760.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-006,LIVER TRANSPLANT WITHOUT MCC,Medical/Surgical,Relative Weights,"$75,142.40 ",IP,"4,660.01","75,142.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-007,LUNG TRANSPLANT,Medical/Surgical,Relative Weights,"$185,280.00 ",IP,"4,660.01","185,280.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Medical/Surgical,Relative Weights,"$86,932.80 ",IP,"4,660.01","86,932.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-010,PANCREAS TRANSPLANT,Medical/Surgical,Relative Weights,"$57,920.00 ",IP,"4,660.01","57,920.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Medical/Surgical,Relative Weights,"$80,342.40 ",IP,"4,660.01","80,342.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Medical/Surgical,Relative Weights,"$61,324.80 ",IP,"4,660.01","61,324.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-013,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$43,580.80 ",IP,"4,660.01","43,580.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Medical/Surgical,Relative Weights,"$170,832.00 ",IP,"4,660.01","170,832.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Medical/Surgical,Relative Weights,"$107,780.80 ",IP,"4,660.01","107,780.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$77,691.20 ",IP,"4,660.01","77,691.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical/Surgical,Relative Weights,"$599,201.60 ",IP,"4,660.01","599,201.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Medical/Surgical,Relative Weights,"$106,875.20 ",IP,"4,660.01","106,875.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Medical/Surgical,Relative Weights,"$165,392.00 ",IP,"4,660.01","165,392.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Medical/Surgical,Relative Weights,"$120,696.00 ",IP,"4,660.01","120,696.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$77,484.80 ",IP,"4,660.01","77,484.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-023,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,Medical/Surgical,Relative Weights,"$90,750.40 ",IP,"4,660.01","90,750.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$63,024.00 ",IP,"4,660.01","63,024.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$71,958.40 ",IP,"4,660.01","71,958.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-026,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$48,992.00 ",IP,"4,660.01","48,992.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$40,228.80 ",IP,"4,660.01","40,228.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$93,169.60 ",IP,"4,660.01","93,169.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Medical/Surgical,Relative Weights,"$52,748.80 ",IP,"4,660.01","52,748.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$37,708.80 ",IP,"4,660.01","37,708.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$69,947.20 ",IP,"4,660.01","69,947.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$35,464.00 ",IP,"4,660.01","35,464.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$27,555.20 ",IP,"4,660.01","27,555.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-034,CAROTID ARTERY STENT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$63,649.60 ",IP,"4,660.01","63,649.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$37,435.20 ",IP,"4,660.01","37,435.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$29,636.80 ",IP,"4,660.01","29,636.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$52,441.60 ",IP,"4,660.01","52,441.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$26,540.80 ",IP,"4,660.01","26,540.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,225.60 ",IP,"4,660.01","18,225.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$61,836.80 ",IP,"4,660.01","61,836.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-041,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR,Medical/Surgical,Relative Weights,"$37,595.20 ",IP,"4,660.01","37,595.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-042,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$30,419.20 ",IP,"4,660.01","30,419.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical/Surgical,Relative Weights,"$29,656.00 ",IP,"4,660.01","29,656.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,182.40 ",IP,"4,660.01","18,182.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical/Surgical,Relative Weights,"$21,892.80 ",IP,"4,660.01","21,892.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical/Surgical,Relative Weights,"$16,713.60 ",IP,"4,660.01","16,713.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$35,124.80 ",IP,"4,660.01","35,124.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$20,280.00 ",IP,"4,660.01","20,280.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical/Surgical,Relative Weights,"$27,804.80 ",IP,"4,660.01","27,804.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical/Surgical,Relative Weights,"$18,036.80 ",IP,"4,660.01","18,036.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,683.20 ",IP,"4,660.01","14,683.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-061,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical/Surgical,Relative Weights,"$46,259.20 ",IP,"4,660.01","46,259.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-062,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical/Surgical,Relative Weights,"$31,812.80 ",IP,"4,660.01","31,812.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$27,355.20 ",IP,"4,660.01","27,355.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical/Surgical,Relative Weights,"$30,702.40 ",IP,"4,660.01","30,702.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,Medical/Surgical,Relative Weights,"$16,320.00 ",IP,"4,660.01","16,320.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,385.60 ",IP,"4,660.01","11,385.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical/Surgical,Relative Weights,"$22,812.80 ",IP,"4,660.01","22,812.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical/Surgical,Relative Weights,"$14,222.40 ",IP,"4,660.01","14,222.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical/Surgical,Relative Weights,"$12,593.60 ",IP,"4,660.01","12,593.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$26,873.60 ",IP,"4,660.01","26,873.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$16,188.80 ",IP,"4,660.01","16,188.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,347.20 ",IP,"4,660.01","12,347.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$23,246.40 ",IP,"4,660.01","23,246.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$16,304.00 ",IP,"4,660.01","16,304.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical/Surgical,Relative Weights,"$26,032.00 ",IP,"4,660.01","26,032.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,758.40 ",IP,"4,660.01","15,758.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical/Surgical,Relative Weights,"$24,526.40 ",IP,"4,660.01","24,526.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical/Surgical,Relative Weights,"$15,198.40 ",IP,"4,660.01","15,198.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,660.80 ",IP,"4,660.01","11,660.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-080,NONTRAUMATIC STUPOR AND COMA WITH MCC,Medical/Surgical,Relative Weights,"$33,526.40 ",IP,"4,660.01","33,526.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-081,NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,371.20 ",IP,"4,660.01","12,371.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical/Surgical,Relative Weights,"$36,222.40 ",IP,"4,660.01","36,222.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical/Surgical,Relative Weights,"$21,504.00 ",IP,"4,660.01","21,504.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,489.60 ",IP,"4,660.01","14,489.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical/Surgical,Relative Weights,"$36,987.20 ",IP,"4,660.01","36,987.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical/Surgical,Relative Weights,"$20,392.00 ",IP,"4,660.01","20,392.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,817.60 ",IP,"4,660.01","13,817.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-088,CONCUSSION WITH MCC,Medical/Surgical,Relative Weights,"$23,283.20 ",IP,"4,660.01","23,283.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-089,CONCUSSION WITH CC,Medical/Surgical,Relative Weights,"$17,016.00 ",IP,"4,660.01","17,016.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,673.60 ",IP,"4,660.01","13,673.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$26,412.80 ",IP,"4,660.01","26,412.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$15,822.40 ",IP,"4,660.01","15,822.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,515.20 ",IP,"4,660.01","12,515.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$58,206.40 ",IP,"4,660.01","58,206.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$40,116.80 ",IP,"4,660.01","40,116.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$37,323.20 ",IP,"4,660.01","37,323.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical/Surgical,Relative Weights,"$60,166.40 ",IP,"4,660.01","60,166.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical/Surgical,Relative Weights,"$33,800.00 ",IP,"4,660.01","33,800.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$22,430.40 ",IP,"4,660.01","22,430.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-100,SEIZURES WITH MCC,Medical/Surgical,Relative Weights,"$30,022.40 ",IP,"4,660.01","30,022.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-101,SEIZURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$14,214.40 ",IP,"4,660.01","14,214.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-102,HEADACHES WITH MCC,Medical/Surgical,Relative Weights,"$18,449.60 ",IP,"4,660.01","18,449.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-103,HEADACHES WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,272.00 ",IP,"4,660.01","13,272.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$35,110.40 ",IP,"4,660.01","35,110.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$23,161.60 ",IP,"4,660.01","23,161.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Medical/Surgical,Relative Weights,"$23,305.60 ",IP,"4,660.01","23,305.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-116,INTRAOCULAR PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$30,123.20 ",IP,"4,660.01","30,123.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-117,INTRAOCULAR PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,659.20 ",IP,"4,660.01","16,659.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical/Surgical,Relative Weights,"$19,049.60 ",IP,"4,660.01","19,049.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,328.00 ",IP,"4,660.01","10,328.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical/Surgical,Relative Weights,"$12,268.80 ",IP,"4,660.01","12,268.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical/Surgical,Relative Weights,"$22,432.00 ",IP,"4,660.01","22,432.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,392.00 ",IP,"4,660.01","13,392.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$34,296.00 ",IP,"4,660.01","34,296.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$20,088.00 ",IP,"4,660.01","20,088.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$24,155.20 ",IP,"4,660.01","24,155.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,704.00 ",IP,"4,660.01","13,704.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-139,SALIVARY GLAND PROCEDURES,Medical/Surgical,Relative Weights,"$19,745.60 ",IP,"4,660.01","19,745.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$63,646.40 ",IP,"4,660.01","63,646.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$35,297.60 ",IP,"4,660.01","35,297.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,681.60 ",IP,"4,660.01","25,681.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$47,676.80 ",IP,"4,660.01","47,676.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-144,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$28,184.00 ",IP,"4,660.01","28,184.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-145,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$19,593.60 ",IP,"4,660.01","19,593.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$32,657.60 ",IP,"4,660.01","32,657.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$20,817.60 ",IP,"4,660.01","20,817.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-148,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,592.00 ",IP,"4,660.01","12,592.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-149,DYSEQUILIBRIUM,Medical/Surgical,Relative Weights,"$11,792.00 ",IP,"4,660.01","11,792.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-150,EPISTAXIS WITH MCC,Medical/Surgical,Relative Weights,"$21,240.00 ",IP,"4,660.01","21,240.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$11,814.40 ",IP,"4,660.01","11,814.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical/Surgical,Relative Weights,"$17,288.00 ",IP,"4,660.01","17,288.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical/Surgical,Relative Weights,"$11,411.20 ",IP,"4,660.01","11,411.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$24,748.80 ",IP,"4,660.01","24,748.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$14,552.00 ",IP,"4,660.01","14,552.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-156,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,534.40 ",IP,"4,660.01","10,534.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical/Surgical,Relative Weights,"$25,219.20 ",IP,"4,660.01","25,219.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical/Surgical,Relative Weights,"$14,403.20 ",IP,"4,660.01","14,403.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,609.60 ",IP,"4,660.01","10,609.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$80,108.80 ",IP,"4,660.01","80,108.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$42,489.60 ",IP,"4,660.01","42,489.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$30,665.60 ",IP,"4,660.01","30,665.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-166,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$59,576.00 ",IP,"4,660.01","59,576.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$29,099.20 ",IP,"4,660.01","29,099.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,670.40 ",IP,"4,660.01","21,670.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical/Surgical,Relative Weights,"$24,736.00 ",IP,"4,660.01","24,736.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical/Surgical,Relative Weights,"$14,204.80 ",IP,"4,660.01","14,204.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-177,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,Medical/Surgical,Relative Weights,"$29,585.60 ",IP,"4,660.01","29,585.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical/Surgical,Relative Weights,"$19,324.80 ",IP,"4,660.01","19,324.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,963.20 ",IP,"4,660.01","13,963.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical/Surgical,Relative Weights,"$27,838.40 ",IP,"4,660.01","27,838.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical/Surgical,Relative Weights,"$17,921.60 ",IP,"4,660.01","17,921.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,672.00 ",IP,"4,660.01","12,672.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical/Surgical,Relative Weights,"$24,942.40 ",IP,"4,660.01","24,942.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical/Surgical,Relative Weights,"$16,654.40 ",IP,"4,660.01","16,654.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-185,MAJOR CHEST TRAUMA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,398.40 ",IP,"4,660.01","12,398.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical/Surgical,Relative Weights,"$24,700.80 ",IP,"4,660.01","24,700.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical/Surgical,Relative Weights,"$16,526.40 ",IP,"4,660.01","16,526.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,672.00 ",IP,"4,660.01","11,672.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical/Surgical,Relative Weights,"$19,617.60 ",IP,"4,660.01","19,617.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical/Surgical,Relative Weights,"$18,001.60 ",IP,"4,660.01","18,001.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical/Surgical,Relative Weights,"$14,148.80 ",IP,"4,660.01","14,148.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,129.60 ",IP,"4,660.01","11,129.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-193,SIMPLE PNEUMONIA AND PLEURISY WITH MCC,Medical/Surgical,Relative Weights,"$20,992.00 ",IP,"4,660.01","20,992.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical/Surgical,Relative Weights,"$13,822.40 ",IP,"4,660.01","13,822.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,652.80 ",IP,"4,660.01","10,652.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical/Surgical,Relative Weights,"$27,817.60 ",IP,"4,660.01","27,817.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical/Surgical,Relative Weights,"$16,112.00 ",IP,"4,660.01","16,112.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,894.40 ",IP,"4,660.01","11,894.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical/Surgical,Relative Weights,"$28,640.00 ",IP,"4,660.01","28,640.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical/Surgical,Relative Weights,"$17,224.00 ",IP,"4,660.01","17,224.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,353.60 ",IP,"4,660.01","11,353.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical/Surgical,Relative Weights,"$15,472.00 ",IP,"4,660.01","15,472.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,312.00 ",IP,"4,660.01","11,312.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical/Surgical,Relative Weights,"$12,697.60 ",IP,"4,660.01","12,697.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$26,956.80 ",IP,"4,660.01","26,956.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical/Surgical,Relative Weights,"$14,176.00 ",IP,"4,660.01","14,176.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,Medical/Surgical,Relative Weights,"$91,777.60 ",IP,"4,660.01","91,777.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical/Surgical,Relative Weights,"$40,716.80 ",IP,"4,660.01","40,716.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Medical/Surgical,Relative Weights,"$168,934.40 ",IP,"4,660.01","168,934.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$160,628.80 ",IP,"4,660.01","160,628.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Medical/Surgical,Relative Weights,"$103,736.00 ",IP,"4,660.01","103,736.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$97,748.80 ",IP,"4,660.01","97,748.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$128,921.60 ",IP,"4,660.01","128,921.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Medical/Surgical,Relative Weights,"$86,484.80 ",IP,"4,660.01","86,484.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$73,278.40 ",IP,"4,660.01","73,278.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Medical/Surgical,Relative Weights,"$127,216.00 ",IP,"4,660.01","127,216.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Medical/Surgical,Relative Weights,"$92,777.60 ",IP,"4,660.01","92,777.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Medical/Surgical,Relative Weights,"$120,305.60 ",IP,"4,660.01","120,305.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Medical/Surgical,Relative Weights,"$89,884.80 ",IP,"4,660.01","89,884.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$105,040.00 ",IP,"4,660.01","105,040.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Medical/Surgical,Relative Weights,"$83,393.60 ",IP,"4,660.01","83,393.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$85,284.80 ",IP,"4,660.01","85,284.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$55,059.20 ",IP,"4,660.01","55,059.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-231,CORONARY BYPASS WITH PTCA WITH MCC,Medical/Surgical,Relative Weights,"$139,454.40 ",IP,"4,660.01","139,454.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-232,CORONARY BYPASS WITH PTCA WITHOUT MCC,Medical/Surgical,Relative Weights,"$95,260.80 ",IP,"4,660.01","95,260.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Medical/Surgical,Relative Weights,"$126,756.80 ",IP,"4,660.01","126,756.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Medical/Surgical,Relative Weights,"$85,376.00 ",IP,"4,660.01","85,376.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$97,665.60 ",IP,"4,660.01","97,665.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Medical/Surgical,Relative Weights,"$65,552.00 ",IP,"4,660.01","65,552.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Medical/Surgical,Relative Weights,"$77,056.00 ",IP,"4,660.01","77,056.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Medical/Surgical,Relative Weights,"$44,620.80 ",IP,"4,660.01","44,620.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,478.40 ",IP,"4,660.01","25,478.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Medical/Surgical,Relative Weights,"$59,641.60 ",IP,"4,660.01","59,641.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Medical/Surgical,Relative Weights,"$40,296.00 ",IP,"4,660.01","40,296.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$33,012.80 ",IP,"4,660.01","33,012.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-245,AICD GENERATOR PROCEDURES,Medical/Surgical,Relative Weights,"$86,684.80 ",IP,"4,660.01","86,684.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Medical/Surgical,Relative Weights,"$49,988.80 ",IP,"4,660.01","49,988.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Medical/Surgical,Relative Weights,"$31,571.20 ",IP,"4,660.01","31,571.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Medical/Surgical,Relative Weights,"$50,595.20 ",IP,"4,660.01","50,595.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Medical/Surgical,Relative Weights,"$29,979.20 ",IP,"4,660.01","29,979.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Medical/Surgical,Relative Weights,"$40,348.80 ",IP,"4,660.01","40,348.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-251,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITHOUT MCC,Medical/Surgical,Relative Weights,"$26,534.40 ",IP,"4,660.01","26,534.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-252,OTHER VASCULAR PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$53,211.20 ",IP,"4,660.01","53,211.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$42,457.60 ",IP,"4,660.01","42,457.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$29,054.40 ",IP,"4,660.01","29,054.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$40,564.80 ",IP,"4,660.01","40,564.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$26,307.20 ",IP,"4,660.01","26,307.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,643.20 ",IP,"4,660.01","18,643.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Medical/Surgical,Relative Weights,"$50,689.60 ",IP,"4,660.01","50,689.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Medical/Surgical,Relative Weights,"$33,427.20 ",IP,"4,660.01","33,427.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Medical/Surgical,Relative Weights,"$57,076.80 ",IP,"4,660.01","57,076.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Medical/Surgical,Relative Weights,"$31,902.40 ",IP,"4,660.01","31,902.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$27,299.20 ",IP,"4,660.01","27,299.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-263,VEIN LIGATION AND STRIPPING,Medical/Surgical,Relative Weights,"$37,011.20 ",IP,"4,660.01","37,011.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$52,057.60 ",IP,"4,660.01","52,057.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-265,AICD LEAD PROCEDURES,Medical/Surgical,Relative Weights,"$53,848.00 ",IP,"4,660.01","53,848.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$112,766.40 ",IP,"4,660.01","112,766.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$89,568.00 ",IP,"4,660.01","89,568.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Medical/Surgical,Relative Weights,"$111,412.80 ",IP,"4,660.01","111,412.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Medical/Surgical,Relative Weights,"$69,041.60 ",IP,"4,660.01","69,041.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$82,992.00 ",IP,"4,660.01","82,992.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$57,046.40 ",IP,"4,660.01","57,046.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$43,012.80 ",IP,"4,660.01","43,012.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$61,227.20 ",IP,"4,660.01","61,227.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$52,585.60 ",IP,"4,660.01","52,585.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH MCC,Medical/Surgical,Relative Weights,"$25,710.40 ",IP,"4,660.01","25,710.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical/Surgical,Relative Weights,"$14,889.60 ",IP,"4,660.01","14,889.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,617.60 ",IP,"4,660.01","11,617.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical/Surgical,Relative Weights,"$29,835.20 ",IP,"4,660.01","29,835.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical/Surgical,Relative Weights,"$11,574.40 ",IP,"4,660.01","11,574.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,915.20 ",IP,"4,660.01","7,915.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical/Surgical,Relative Weights,"$34,180.80 ",IP,"4,660.01","34,180.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical/Surgical,Relative Weights,"$17,841.60 ",IP,"4,660.01","17,841.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-288,ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,Medical/Surgical,Relative Weights,"$42,966.40 ",IP,"4,660.01","42,966.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical/Surgical,Relative Weights,"$26,297.60 ",IP,"4,660.01","26,297.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,430.40 ",IP,"4,660.01","16,430.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical/Surgical,Relative Weights,"$20,292.80 ",IP,"4,660.01","20,292.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical/Surgical,Relative Weights,"$13,816.00 ",IP,"4,660.01","13,816.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,438.40 ",IP,"4,660.01","9,438.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical/Surgical,Relative Weights,"$20,524.80 ",IP,"4,660.01","20,524.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,745.60 ",IP,"4,660.01","15,745.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-296,CARDIAC ARREST- UNEXPLAINED WITH MCC,Medical/Surgical,Relative Weights,"$25,523.20 ",IP,"4,660.01","25,523.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical/Surgical,Relative Weights,"$11,312.00 ",IP,"4,660.01","11,312.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$7,820.80 ",IP,"4,660.01","7,820.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$24,521.60 ",IP,"4,660.01","24,521.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$16,700.80 ",IP,"4,660.01","16,700.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,889.60 ",IP,"4,660.01","11,889.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical/Surgical,Relative Weights,"$17,516.80 ",IP,"4,660.01","17,516.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$10,841.60 ",IP,"4,660.01","10,841.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-304,HYPERTENSION WITH MCC,Medical/Surgical,Relative Weights,"$17,552.00 ",IP,"4,660.01","17,552.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical/Surgical,Relative Weights,"$11,838.40 ",IP,"4,660.01","11,838.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$24,118.40 ",IP,"4,660.01","24,118.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,926.40 ",IP,"4,660.01","13,926.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$19,214.40 ",IP,"4,660.01","19,214.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$12,008.00 ",IP,"4,660.01","12,008.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-310,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,947.20 ",IP,"4,660.01","8,947.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-311,ANGINA PECTORIS,Medical/Surgical,Relative Weights,"$11,176.00 ",IP,"4,660.01","11,176.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical/Surgical,Relative Weights,"$13,419.20 ",IP,"4,660.01","13,419.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-313,CHEST PAIN,Medical/Surgical,Relative Weights,"$11,542.40 ",IP,"4,660.01","11,542.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$33,355.20 ",IP,"4,660.01","33,355.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$15,574.40 ",IP,"4,660.01","15,574.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,574.40 ",IP,"4,660.01","11,574.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$69,086.40 ",IP,"4,660.01","69,086.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$38,489.60 ",IP,"4,660.01","38,489.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$85,060.80 ",IP,"4,660.01","85,060.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$41,035.20 ",IP,"4,660.01","41,035.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$26,670.40 ",IP,"4,660.01","26,670.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$78,179.20 ",IP,"4,660.01","78,179.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$40,788.80 ",IP,"4,660.01","40,788.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$27,368.00 ",IP,"4,660.01","27,368.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-332,RECTAL RESECTION WITH MCC,Medical/Surgical,Relative Weights,"$66,584.00 ",IP,"4,660.01","66,584.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-333,RECTAL RESECTION WITH CC,Medical/Surgical,Relative Weights,"$34,260.80 ",IP,"4,660.01","34,260.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,737.60 ",IP,"4,660.01","25,737.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Medical/Surgical,Relative Weights,"$62,616.00 ",IP,"4,660.01","62,616.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Medical/Surgical,Relative Weights,"$36,660.80 ",IP,"4,660.01","36,660.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$26,196.80 ",IP,"4,660.01","26,196.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,"$44,756.80 ",IP,"4,660.01","44,756.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-339,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Medical/Surgical,Relative Weights,"$27,158.40 ",IP,"4,660.01","27,158.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-340,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$19,652.80 ",IP,"4,660.01","19,652.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,"$37,158.40 ",IP,"4,660.01","37,158.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Medical/Surgical,Relative Weights,"$22,926.40 ",IP,"4,660.01","22,926.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,737.60 ",IP,"4,660.01","17,737.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$45,094.40 ",IP,"4,660.01","45,094.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$25,260.80 ",IP,"4,660.01","25,260.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$20,406.40 ",IP,"4,660.01","20,406.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$39,435.20 ",IP,"4,660.01","39,435.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$21,569.60 ",IP,"4,660.01","21,569.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,668.80 ",IP,"4,660.01","15,668.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$39,276.80 ",IP,"4,660.01","39,276.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$23,883.20 ",IP,"4,660.01","23,883.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,670.40 ",IP,"4,660.01","17,670.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Medical/Surgical,Relative Weights,"$48,398.40 ",IP,"4,660.01","48,398.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,Medical/Surgical,Relative Weights,"$28,556.80 ",IP,"4,660.01","28,556.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,763.20 ",IP,"4,660.01","21,763.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$68,924.80 ",IP,"4,660.01","68,924.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$36,296.00 ",IP,"4,660.01","36,296.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,585.60 ",IP,"4,660.01","21,585.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$31,185.60 ",IP,"4,660.01","31,185.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$17,235.20 ",IP,"4,660.01","17,235.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,969.60 ",IP,"4,660.01","11,969.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical/Surgical,Relative Weights,"$27,699.20 ",IP,"4,660.01","27,699.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical/Surgical,Relative Weights,"$16,468.80 ",IP,"4,660.01","16,468.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,913.60 ",IP,"4,660.01","11,913.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$33,179.20 ",IP,"4,660.01","33,179.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$19,321.60 ",IP,"4,660.01","19,321.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,382.40 ",IP,"4,660.01","14,382.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical/Surgical,Relative Weights,"$28,819.20 ",IP,"4,660.01","28,819.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical/Surgical,Relative Weights,"$15,896.00 ",IP,"4,660.01","15,896.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,195.20 ",IP,"4,660.01","10,195.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical/Surgical,Relative Weights,"$30,185.60 ",IP,"4,660.01","30,185.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical/Surgical,Relative Weights,"$16,948.80 ",IP,"4,660.01","16,948.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,297.60 ",IP,"4,660.01","12,297.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical/Surgical,Relative Weights,"$21,001.60 ",IP,"4,660.01","21,001.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical/Surgical,Relative Weights,"$14,284.80 ",IP,"4,660.01","14,284.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical/Surgical,Relative Weights,"$25,956.80 ",IP,"4,660.01","25,956.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-386,INFLAMMATORY BOWEL DISEASE WITH CC,Medical/Surgical,Relative Weights,"$15,921.60 ",IP,"4,660.01","15,921.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-387,INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,435.20 ",IP,"4,660.01","11,435.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical/Surgical,Relative Weights,"$24,233.60 ",IP,"4,660.01","24,233.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical/Surgical,Relative Weights,"$13,171.20 ",IP,"4,660.01","13,171.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,329.60 ",IP,"4,660.01","9,329.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$19,987.20 ",IP,"4,660.01","19,987.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,252.80 ",IP,"4,660.01","12,252.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$26,579.20 ",IP,"4,660.01","26,579.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$15,054.40 ",IP,"4,660.01","15,054.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,424.00 ",IP,"4,660.01","10,424.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$91,801.60 ",IP,"4,660.01","91,801.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-406,PANCREAS- LIVER AND SHUNT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$46,094.40 ",IP,"4,660.01","46,094.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-407,PANCREAS- LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$33,888.00 ",IP,"4,660.01","33,888.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Medical/Surgical,Relative Weights,"$60,046.40 ",IP,"4,660.01","60,046.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Medical/Surgical,Relative Weights,"$33,862.40 ",IP,"4,660.01","33,862.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-410,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,092.80 ",IP,"4,660.01","25,092.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-411,CHOLECYSTECTOMY WITH C.D.E. WITH MCC,Medical/Surgical,Relative Weights,"$60,056.00 ",IP,"4,660.01","60,056.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Medical/Surgical,Relative Weights,"$36,440.00 ",IP,"4,660.01","36,440.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$27,694.40 ",IP,"4,660.01","27,694.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Medical/Surgical,Relative Weights,"$58,052.80 ",IP,"4,660.01","58,052.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Medical/Surgical,Relative Weights,"$32,507.20 ",IP,"4,660.01","32,507.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$22,756.80 ",IP,"4,660.01","22,756.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Medical/Surgical,Relative Weights,"$38,788.80 ",IP,"4,660.01","38,788.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Medical/Surgical,Relative Weights,"$27,024.00 ",IP,"4,660.01","27,024.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,044.80 ",IP,"4,660.01","21,044.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$56,264.00 ",IP,"4,660.01","56,264.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$30,520.00 ",IP,"4,660.01","30,520.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$23,257.60 ",IP,"4,660.01","23,257.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$66,974.40 ",IP,"4,660.01","66,974.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$36,545.60 ",IP,"4,660.01","36,545.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$24,683.20 ",IP,"4,660.01","24,683.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical/Surgical,Relative Weights,"$30,092.80 ",IP,"4,660.01","30,092.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical/Surgical,Relative Weights,"$16,478.40 ",IP,"4,660.01","16,478.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,931.20 ",IP,"4,660.01","9,931.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical/Surgical,Relative Weights,"$28,054.40 ",IP,"4,660.01","28,054.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical/Surgical,Relative Weights,"$17,944.00 ",IP,"4,660.01","17,944.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,334.40 ",IP,"4,660.01","14,334.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$25,564.80 ",IP,"4,660.01","25,564.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$13,523.20 ",IP,"4,660.01","13,523.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,700.80 ",IP,"4,660.01","9,700.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical/Surgical,Relative Weights,"$30,072.00 ",IP,"4,660.01","30,072.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical/Surgical,Relative Weights,"$14,880.00 ",IP,"4,660.01","14,880.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,611.20 ",IP,"4,660.01","10,611.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical/Surgical,Relative Weights,"$26,745.60 ",IP,"4,660.01","26,745.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical/Surgical,Relative Weights,"$17,240.00 ",IP,"4,660.01","17,240.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-446,DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,065.60 ",IP,"4,660.01","13,065.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-453,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,Medical/Surgical,Relative Weights,"$147,008.00 ",IP,"4,660.01","147,008.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Medical/Surgical,Relative Weights,"$97,489.60 ",IP,"4,660.01","97,489.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$76,500.80 ",IP,"4,660.01","76,500.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Medical/Surgical,Relative Weights,"$137,600.00 ",IP,"4,660.01","137,600.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Medical/Surgical,Relative Weights,"$103,934.40 ",IP,"4,660.01","103,934.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$80,121.60 ",IP,"4,660.01","80,121.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Medical/Surgical,Relative Weights,"$107,736.00 ",IP,"4,660.01","107,736.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Medical/Surgical,Relative Weights,"$62,891.20 ",IP,"4,660.01","62,891.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Medical/Surgical,Relative Weights,"$97,307.20 ",IP,"4,660.01","97,307.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Medical/Surgical,Relative Weights,"$50,262.40 ",IP,"4,660.01","50,262.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$85,924.80 ",IP,"4,660.01","85,924.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$47,614.40 ",IP,"4,660.01","47,614.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$29,505.60 ",IP,"4,660.01","29,505.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Medical/Surgical,Relative Weights,"$85,531.20 ",IP,"4,660.01","85,531.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT WITH CC,Medical/Surgical,Relative Weights,"$57,240.00 ",IP,"4,660.01","57,240.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$44,838.40 ",IP,"4,660.01","44,838.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Medical/Surgical,Relative Weights,"$49,374.40 ",IP,"4,660.01","49,374.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Medical/Surgical,Relative Weights,"$30,404.80 ",IP,"4,660.01","30,404.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Medical/Surgical,Relative Weights,"$80,315.20 ",IP,"4,660.01","80,315.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Medical/Surgical,Relative Weights,"$48,859.20 ",IP,"4,660.01","48,859.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$40,624.00 ",IP,"4,660.01","40,624.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$65,217.60 ",IP,"4,660.01","65,217.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$35,140.80 ",IP,"4,660.01","35,140.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,564.80 ",IP,"4,660.01","18,564.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical/Surgical,Relative Weights,"$53,742.40 ",IP,"4,660.01","53,742.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical/Surgical,Relative Weights,"$37,734.40 ",IP,"4,660.01","37,734.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$28,952.00 ",IP,"4,660.01","28,952.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Medical/Surgical,Relative Weights,"$48,412.80 ",IP,"4,660.01","48,412.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Medical/Surgical,Relative Weights,"$33,537.60 ",IP,"4,660.01","33,537.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-482,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$26,332.80 ",IP,"4,660.01","26,332.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-483,MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,Medical/Surgical,Relative Weights,"$38,171.20 ",IP,"4,660.01","38,171.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Medical/Surgical,Relative Weights,"$54,553.60 ",IP,"4,660.01","54,553.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Medical/Surgical,Relative Weights,"$34,390.40 ",IP,"4,660.01","34,390.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$26,243.20 ",IP,"4,660.01","26,243.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Medical/Surgical,Relative Weights,"$31,611.20 ",IP,"4,660.01","31,611.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$20,771.20 ",IP,"4,660.01","20,771.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Medical/Surgical,Relative Weights,"$55,520.00 ",IP,"4,660.01","55,520.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Medical/Surgical,Relative Weights,"$37,212.80 ",IP,"4,660.01","37,212.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$29,627.20 ",IP,"4,660.01","29,627.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Medical/Surgical,Relative Weights,"$58,270.40 ",IP,"4,660.01","58,270.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Medical/Surgical,Relative Weights,"$31,782.40 ",IP,"4,660.01","31,782.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$23,224.00 ",IP,"4,660.01","23,224.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Medical/Surgical,Relative Weights,"$41,339.20 ",IP,"4,660.01","41,339.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$19,184.00 ",IP,"4,660.01","19,184.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$51,032.00 ",IP,"4,660.01","51,032.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$28,065.60 ",IP,"4,660.01","28,065.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,324.80 ",IP,"4,660.01","21,324.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-503,FOOT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$42,249.60 ",IP,"4,660.01","42,249.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-504,FOOT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$28,400.00 ",IP,"4,660.01","28,400.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$28,400.00 ",IP,"4,660.01","28,400.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Medical/Surgical,Relative Weights,"$23,737.60 ",IP,"4,660.01","23,737.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$32,974.40 ",IP,"4,660.01","32,974.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$22,555.20 ",IP,"4,660.01","22,555.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-509,ARTHROSCOPY,Medical/Surgical,Relative Weights,"$26,984.00 ",IP,"4,660.01","26,984.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$43,899.20 ",IP,"4,660.01","43,899.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$31,478.40 ",IP,"4,660.01","31,478.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$24,872.00 ",IP,"4,660.01","24,872.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$25,152.00 ",IP,"4,660.01","25,152.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-514,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,985.60 ",IP,"4,660.01","15,985.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-515,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$50,249.60 ",IP,"4,660.01","50,249.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$31,404.80 ",IP,"4,660.01","31,404.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$22,371.20 ",IP,"4,660.01","22,371.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Medical/Surgical,Relative Weights,"$57,390.40 ",IP,"4,660.01","57,390.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Medical/Surgical,Relative Weights,"$31,360.00 ",IP,"4,660.01","31,360.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$22,692.80 ",IP,"4,660.01","22,692.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Medical/Surgical,Relative Weights,"$49,059.20 ",IP,"4,660.01","49,059.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Medical/Surgical,Relative Weights,"$35,030.40 ",IP,"4,660.01","35,030.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical/Surgical,Relative Weights,"$22,659.20 ",IP,"4,660.01","22,659.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,643.20 ",IP,"4,660.01","12,643.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical/Surgical,Relative Weights,"$19,724.80 ",IP,"4,660.01","19,724.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,347.20 ",IP,"4,660.01","12,347.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical/Surgical,Relative Weights,"$14,966.40 ",IP,"4,660.01","14,966.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,571.20 ",IP,"4,660.01","11,571.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical/Surgical,Relative Weights,"$31,163.20 ",IP,"4,660.01","31,163.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical/Surgical,Relative Weights,"$20,825.60 ",IP,"4,660.01","20,825.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,491.20 ",IP,"4,660.01","13,491.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$28,947.20 ",IP,"4,660.01","28,947.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$16,723.20 ",IP,"4,660.01","16,723.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,443.20 ",IP,"4,660.01","12,443.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$40,049.60 ",IP,"4,660.01","40,049.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$19,328.00 ",IP,"4,660.01","19,328.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,337.60 ",IP,"4,660.01","13,337.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical/Surgical,Relative Weights,"$32,812.80 ",IP,"4,660.01","32,812.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-549,SEPTIC ARTHRITIS WITH CC,Medical/Surgical,Relative Weights,"$19,998.40 ",IP,"4,660.01","19,998.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-550,SEPTIC ARTHRITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,062.40 ",IP,"4,660.01","14,062.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical/Surgical,Relative Weights,"$26,038.40 ",IP,"4,660.01","26,038.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical/Surgical,Relative Weights,"$15,094.40 ",IP,"4,660.01","15,094.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical/Surgical,Relative Weights,"$20,344.00 ",IP,"4,660.01","20,344.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,680.00 ",IP,"4,660.01","12,680.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical/Surgical,Relative Weights,"$21,896.00 ",IP,"4,660.01","21,896.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,939.20 ",IP,"4,660.01","12,939.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-557,TENDONITIS- MYOSITIS AND BURSITIS WITH MCC,Medical/Surgical,Relative Weights,"$22,385.60 ",IP,"4,660.01","22,385.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,782.40 ",IP,"4,660.01","13,782.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical/Surgical,Relative Weights,"$29,844.80 ",IP,"4,660.01","29,844.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical/Surgical,Relative Weights,"$17,216.00 ",IP,"4,660.01","17,216.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,678.40 ",IP,"4,660.01","12,678.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical/Surgical,Relative Weights,"$22,588.80 ",IP,"4,660.01","22,588.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,955.20 ",IP,"4,660.01","13,955.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$24,377.60 ",IP,"4,660.01","24,377.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-565,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$16,148.80 ",IP,"4,660.01","16,148.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,030.40 ",IP,"4,660.01","12,030.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Medical/Surgical,Relative Weights,"$45,467.20 ",IP,"4,660.01","45,467.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Medical/Surgical,Relative Weights,"$26,166.40 ",IP,"4,660.01","26,166.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,670.40 ",IP,"4,660.01","17,670.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Medical/Surgical,Relative Weights,"$88,625.60 ",IP,"4,660.01","88,625.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Medical/Surgical,Relative Weights,"$51,944.00 ",IP,"4,660.01","51,944.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$28,211.20 ",IP,"4,660.01","28,211.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Medical/Surgical,Relative Weights,"$81,019.20 ",IP,"4,660.01","81,019.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Medical/Surgical,Relative Weights,"$40,793.60 ",IP,"4,660.01","40,793.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,523.20 ",IP,"4,660.01","25,523.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$50,318.40 ",IP,"4,660.01","50,318.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$27,660.80 ",IP,"4,660.01","27,660.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$22,028.80 ",IP,"4,660.01","22,028.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Medical/Surgical,Relative Weights,"$26,289.60 ",IP,"4,660.01","26,289.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-583,MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$24,664.00 ",IP,"4,660.01","24,664.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$29,387.20 ",IP,"4,660.01","29,387.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$27,833.60 ",IP,"4,660.01","27,833.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-592,SKIN ULCERS WITH MCC,Medical/Surgical,Relative Weights,"$27,108.80 ",IP,"4,660.01","27,108.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-593,SKIN ULCERS WITH CC,Medical/Surgical,Relative Weights,"$18,249.60 ",IP,"4,660.01","18,249.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,056.00 ",IP,"4,660.01","13,056.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$32,264.00 ",IP,"4,660.01","32,264.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-596,MAJOR SKIN DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$15,915.20 ",IP,"4,660.01","15,915.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-597,MALIGNANT BREAST DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$26,304.00 ",IP,"4,660.01","26,304.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$17,806.40 ",IP,"4,660.01","17,806.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,742.40 ",IP,"4,660.01","10,742.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical/Surgical,Relative Weights,"$15,950.40 ",IP,"4,660.01","15,950.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,988.80 ",IP,"4,660.01","10,988.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-602,CELLULITIS WITH MCC,Medical/Surgical,Relative Weights,"$23,200.00 ",IP,"4,660.01","23,200.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,657.60 ",IP,"4,660.01","13,657.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-604,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical/Surgical,Relative Weights,"$23,646.40 ",IP,"4,660.01","23,646.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical/Surgical,Relative Weights,"$14,462.40 ",IP,"4,660.01","14,462.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$24,193.60 ",IP,"4,660.01","24,193.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,251.20 ",IP,"4,660.01","13,251.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$38,235.20 ",IP,"4,660.01","38,235.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-615,ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,200.00 ",IP,"4,660.01","25,200.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$63,459.20 ",IP,"4,660.01","63,459.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$32,476.80 ",IP,"4,660.01","32,476.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$20,851.20 ",IP,"4,660.01","20,851.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Medical/Surgical,Relative Weights,"$48,987.20 ",IP,"4,660.01","48,987.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Medical/Surgical,Relative Weights,"$28,203.20 ",IP,"4,660.01","28,203.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,553.60 ",IP,"4,660.01","25,553.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$57,838.40 ",IP,"4,660.01","57,838.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$29,944.00 ",IP,"4,660.01","29,944.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,582.40 ",IP,"4,660.01","17,582.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$45,443.20 ",IP,"4,660.01","45,443.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-626,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$26,446.40 ",IP,"4,660.01","26,446.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-627,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,924.80 ",IP,"4,660.01","18,924.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$58,870.40 ",IP,"4,660.01","58,870.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$37,524.80 ",IP,"4,660.01","37,524.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-630,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$22,548.80 ",IP,"4,660.01","22,548.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-637,DIABETES WITH MCC,Medical/Surgical,Relative Weights,"$22,025.60 ",IP,"4,660.01","22,025.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-638,DIABETES WITH CC,Medical/Surgical,Relative Weights,"$14,070.40 ",IP,"4,660.01","14,070.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,753.60 ",IP,"4,660.01","9,753.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical/Surgical,Relative Weights,"$19,692.80 ",IP,"4,660.01","19,692.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,067.20 ",IP,"4,660.01","12,067.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical/Surgical,Relative Weights,"$20,636.80 ",IP,"4,660.01","20,636.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$26,683.20 ",IP,"4,660.01","26,683.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$16,316.80 ",IP,"4,660.01","16,316.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$12,297.60 ",IP,"4,660.01","12,297.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Medical/Surgical,Relative Weights,"$72,331.20 ",IP,"4,660.01","72,331.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Medical/Surgical,Relative Weights,"$59,174.40 ",IP,"4,660.01","59,174.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-652,KIDNEY TRANSPLANT,Medical/Surgical,Relative Weights,"$50,961.60 ",IP,"4,660.01","50,961.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$87,347.20 ",IP,"4,660.01","87,347.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$46,444.80 ",IP,"4,660.01","46,444.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$33,284.80 ",IP,"4,660.01","33,284.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Medical/Surgical,Relative Weights,"$52,560.00 ",IP,"4,660.01","52,560.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Medical/Surgical,Relative Weights,"$30,955.20 ",IP,"4,660.01","30,955.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,246.40 ",IP,"4,660.01","25,246.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Medical/Surgical,Relative Weights,"$42,662.40 ",IP,"4,660.01","42,662.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-660,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,Medical/Surgical,Relative Weights,"$23,089.60 ",IP,"4,660.01","23,089.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,019.20 ",IP,"4,660.01","17,019.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$46,996.80 ",IP,"4,660.01","46,996.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$25,592.00 ",IP,"4,660.01","25,592.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,940.80 ",IP,"4,660.01","18,940.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-665,PROSTATECTOMY WITH MCC,Medical/Surgical,Relative Weights,"$48,667.20 ",IP,"4,660.01","48,667.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-666,PROSTATECTOMY WITH CC,Medical/Surgical,Relative Weights,"$27,835.20 ",IP,"4,660.01","27,835.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-667,PROSTATECTOMY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,960.00 ",IP,"4,660.01","15,960.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-668,TRANSURETHRAL PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$44,900.80 ",IP,"4,660.01","44,900.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$25,016.00 ",IP,"4,660.01","25,016.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,656.00 ",IP,"4,660.01","15,656.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$28,500.80 ",IP,"4,660.01","28,500.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,406.40 ",IP,"4,660.01","18,406.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$55,492.80 ",IP,"4,660.01","55,492.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$38,131.20 ",IP,"4,660.01","38,131.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$28,075.20 ",IP,"4,660.01","28,075.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-682,RENAL FAILURE WITH MCC,Medical/Surgical,Relative Weights,"$23,563.20 ",IP,"4,660.01","23,563.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-683,RENAL FAILURE WITH CC,Medical/Surgical,Relative Weights,"$14,068.80 ",IP,"4,660.01","14,068.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,726.40 ",IP,"4,660.01","9,726.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical/Surgical,Relative Weights,"$30,004.80 ",IP,"4,660.01","30,004.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical/Surgical,Relative Weights,"$16,801.60 ",IP,"4,660.01","16,801.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,972.80 ",IP,"4,660.01","10,972.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical/Surgical,Relative Weights,"$17,827.20 ",IP,"4,660.01","17,827.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,704.00 ",IP,"4,660.01","12,704.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-693,URINARY STONES WITH MCC,Medical/Surgical,Relative Weights,"$21,368.00 ",IP,"4,660.01","21,368.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,339.20 ",IP,"4,660.01","12,339.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical/Surgical,Relative Weights,"$18,203.20 ",IP,"4,660.01","18,203.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical/Surgical,Relative Weights,"$11,070.40 ",IP,"4,660.01","11,070.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-697,URETHRAL STRICTURE,Medical/Surgical,Relative Weights,"$15,988.80 ",IP,"4,660.01","15,988.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$25,769.60 ",IP,"4,660.01","25,769.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$16,432.00 ",IP,"4,660.01","16,432.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,944.00 ",IP,"4,660.01","11,944.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$30,755.20 ",IP,"4,660.01","30,755.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$23,859.20 ",IP,"4,660.01","23,859.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-709,PENIS PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$37,054.40 ",IP,"4,660.01","37,054.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-710,PENIS PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$25,625.60 ",IP,"4,660.01","25,625.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$34,105.60 ",IP,"4,660.01","34,105.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,960.00 ",IP,"4,660.01","16,960.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Medical/Surgical,Relative Weights,"$23,894.40 ",IP,"4,660.01","23,894.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,860.80 ",IP,"4,660.01","14,860.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Medical/Surgical,Relative Weights,"$32,345.60 ",IP,"4,660.01","32,345.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$20,412.80 ",IP,"4,660.01","20,412.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Medical/Surgical,Relative Weights,"$28,809.60 ",IP,"4,660.01","28,809.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$19,753.60 ",IP,"4,660.01","19,753.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$27,401.60 ",IP,"4,660.01","27,401.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$17,470.40 ",IP,"4,660.01","17,470.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,369.60 ",IP,"4,660.01","10,369.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical/Surgical,Relative Weights,"$20,568.00 ",IP,"4,660.01","20,568.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical/Surgical,Relative Weights,"$11,915.20 ",IP,"4,660.01","11,915.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$22,736.00 ",IP,"4,660.01","22,736.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,891.20 ",IP,"4,660.01","12,891.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical/Surgical,Relative Weights,"$16,120.00 ",IP,"4,660.01","16,120.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,102.40 ",IP,"4,660.01","9,102.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-734,PELVIC EVISCERATION- RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Medical/Surgical,Relative Weights,"$35,588.80 ",IP,"4,660.01","35,588.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-735,PELVIC EVISCERATION- RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$22,617.60 ",IP,"4,660.01","22,617.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$68,171.20 ",IP,"4,660.01","68,171.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$32,929.60 ",IP,"4,660.01","32,929.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-738,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$23,614.40 ",IP,"4,660.01","23,614.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-739,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,Medical/Surgical,Relative Weights,"$61,184.00 ",IP,"4,660.01","61,184.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Medical/Surgical,Relative Weights,"$28,825.60 ",IP,"4,660.01","28,825.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$20,478.40 ",IP,"4,660.01","20,478.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Medical/Surgical,Relative Weights,"$27,489.60 ",IP,"4,660.01","27,489.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,124.80 ",IP,"4,660.01","18,124.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Medical/Surgical,Relative Weights,"$28,726.40 ",IP,"4,660.01","28,726.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,720.00 ",IP,"4,660.01","18,720.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-746,VAGINA- CERVIX AND VULVA PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$25,784.00 ",IP,"4,660.01","25,784.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,025.60 ",IP,"4,660.01","15,025.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Medical/Surgical,Relative Weights,"$21,561.60 ",IP,"4,660.01","21,561.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$43,420.80 ",IP,"4,660.01","43,420.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$23,420.80 ",IP,"4,660.01","23,420.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$29,219.20 ",IP,"4,660.01","29,219.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$18,068.80 ",IP,"4,660.01","18,068.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-756,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,694.40 ",IP,"4,660.01","14,694.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-757,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical/Surgical,Relative Weights,"$24,395.20 ",IP,"4,660.01","24,395.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical/Surgical,Relative Weights,"$15,515.20 ",IP,"4,660.01","15,515.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,934.40 ",IP,"4,660.01","10,934.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical/Surgical,Relative Weights,"$14,721.60 ",IP,"4,660.01","14,721.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$9,452.80 ",IP,"4,660.01","9,452.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-768,VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,Medical/Surgical,Relative Weights,"$18,713.60 ",IP,"4,660.01","18,713.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$25,881.60 ",IP,"4,660.01","25,881.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Medical/Surgical,Relative Weights,"$14,236.80 ",IP,"4,660.01","14,236.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical/Surgical,Relative Weights,"$12,392.00 ",IP,"4,660.01","12,392.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-779,ABORTION WITHOUT D&C,Medical/Surgical,Relative Weights,"$16,944.00 ",IP,"4,660.01","16,944.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Medical/Surgical,Relative Weights,"$29,998.40 ",IP,"4,660.01","29,998.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Medical/Surgical,Relative Weights,"$17,534.40 ",IP,"4,660.01","17,534.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,668.80 ",IP,"4,660.01","14,668.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Medical/Surgical,Relative Weights,"$25,510.40 ",IP,"4,660.01","25,510.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Medical/Surgical,Relative Weights,"$17,030.40 ",IP,"4,660.01","17,030.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,198.40 ",IP,"4,660.01","14,198.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Medical/Surgical,Relative Weights,"$27,520.00 ",IP,"4,660.01","27,520.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Medical/Surgical,Relative Weights,"$90,753.60 ",IP,"4,660.01","90,753.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-791,PREMATURITY WITH MAJOR PROBLEMS,Medical/Surgical,Relative Weights,"$61,980.80 ",IP,"4,660.01","61,980.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-792,PREMATURITY WITHOUT MAJOR PROBLEMS,Medical/Surgical,Relative Weights,"$37,398.40 ",IP,"4,660.01","37,398.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Medical/Surgical,Relative Weights,"$63,667.20 ",IP,"4,660.01","63,667.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Medical/Surgical,Relative Weights,"$22,534.40 ",IP,"4,660.01","22,534.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-795,NORMAL NEWBORN,Medical/Surgical,Relative Weights,"$3,051.20 ",IP,"3,051.20","5,358.42",,,,,,,,,,,,
Aetna Commercial,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Medical/Surgical,Relative Weights,"$17,132.80 ",IP,"4,660.01","17,132.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Medical/Surgical,Relative Weights,"$14,710.40 ",IP,"4,660.01","14,710.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,240.00 ",IP,"4,660.01","13,240.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-799,SPLENECTOMY WITH MCC,Medical/Surgical,Relative Weights,"$82,358.40 ",IP,"4,660.01","82,358.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-800,SPLENECTOMY WITH CC,Medical/Surgical,Relative Weights,"$47,262.40 ",IP,"4,660.01","47,262.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$26,944.00 ",IP,"4,660.01","26,944.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Medical/Surgical,Relative Weights,"$59,387.20 ",IP,"4,660.01","59,387.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Medical/Surgical,Relative Weights,"$30,184.00 ",IP,"4,660.01","30,184.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,854.40 ",IP,"4,660.01","21,854.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Medical/Surgical,Relative Weights,"$16,478.40 ",IP,"4,660.01","16,478.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Medical/Surgical,Relative Weights,"$11,753.60 ",IP,"4,660.01","11,753.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,276.80 ",IP,"4,660.01","10,276.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$34,972.80 ",IP,"4,660.01","34,972.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$19,574.40 ",IP,"4,660.01","19,574.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,387.20 ",IP,"4,660.01","15,387.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$22,068.80 ",IP,"4,660.01","22,068.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical/Surgical,Relative Weights,"$14,084.80 ",IP,"4,660.01","14,084.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-813,COAGULATION DISORDERS,Medical/Surgical,Relative Weights,"$24,721.60 ",IP,"4,660.01","24,721.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical/Surgical,Relative Weights,"$30,267.20 ",IP,"4,660.01","30,267.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical/Surgical,Relative Weights,"$15,894.40 ",IP,"4,660.01","15,894.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-816,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$10,577.60 ",IP,"4,660.01","10,577.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$36,908.80 ",IP,"4,660.01","36,908.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$21,756.80 ",IP,"4,660.01","21,756.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,795.20 ",IP,"4,660.01","15,795.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$91,067.20 ",IP,"4,660.01","91,067.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$34,483.20 ",IP,"4,660.01","34,483.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$20,024.00 ",IP,"4,660.01","20,024.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$72,028.80 ",IP,"4,660.01","72,028.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$37,830.40 ",IP,"4,660.01","37,830.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$22,424.00 ",IP,"4,660.01","22,424.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$80,712.00 ",IP,"4,660.01","80,712.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$40,009.60 ",IP,"4,660.01","40,009.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$26,784.00 ",IP,"4,660.01","26,784.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Medical/Surgical,Relative Weights,"$51,334.40 ",IP,"4,660.01","51,334.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$23,712.00 ",IP,"4,660.01","23,712.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$17,948.80 ",IP,"4,660.01","17,948.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$12,452.80 ",IP,"4,660.01","12,452.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$8,592.00 ",IP,"4,660.01","8,592.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-834,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$96,835.20 ",IP,"4,660.01","96,835.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$33,819.20 ",IP,"4,660.01","33,819.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,776.00 ",IP,"4,660.01","18,776.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical/Surgical,Relative Weights,"$91,188.80 ",IP,"4,660.01","91,188.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical/Surgical,Relative Weights,"$36,163.20 ",IP,"4,660.01","36,163.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$23,795.20 ",IP,"4,660.01","23,795.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical/Surgical,Relative Weights,"$51,528.00 ",IP,"4,660.01","51,528.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-841,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,Medical/Surgical,Relative Weights,"$25,945.60 ",IP,"4,660.01","25,945.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,552.00 ",IP,"4,660.01","17,552.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$30,521.60 ",IP,"4,660.01","30,521.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$18,947.20 ",IP,"4,660.01","18,947.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$13,582.40 ",IP,"4,660.01","13,582.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,"$42,766.40 ",IP,"4,660.01","42,766.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical/Surgical,Relative Weights,"$21,377.60 ",IP,"4,660.01","21,377.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$16,516.80 ",IP,"4,660.01","16,516.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-849,RADIOTHERAPY,Medical/Surgical,Relative Weights,"$39,897.60 ",IP,"4,660.01","39,897.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$79,484.80 ",IP,"4,660.01","79,484.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$33,955.20 ",IP,"4,660.01","33,955.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$24,316.80 ",IP,"4,660.01","24,316.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$74,622.40 ",IP,"4,660.01","74,622.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Medical/Surgical,Relative Weights,"$33,638.40 ",IP,"4,660.01","33,638.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,753.60 ",IP,"4,660.01","21,753.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-862,POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,Medical/Surgical,Relative Weights,"$30,347.20 ",IP,"4,660.01","30,347.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-863,POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,Medical/Surgical,Relative Weights,"$16,182.40 ",IP,"4,660.01","16,182.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical/Surgical,Relative Weights,"$14,024.00 ",IP,"4,660.01","14,024.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical/Surgical,Relative Weights,"$23,644.80 ",IP,"4,660.01","23,644.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,424.00 ",IP,"4,660.01","13,424.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$35,793.60 ",IP,"4,660.01","35,793.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical/Surgical,Relative Weights,"$17,056.00 ",IP,"4,660.01","17,056.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,656.00 ",IP,"4,660.01","11,656.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical/Surgical,Relative Weights,"$103,024.00 ",IP,"4,660.01","103,024.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical/Surgical,Relative Weights,"$29,955.20 ",IP,"4,660.01","29,955.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical/Surgical,Relative Weights,"$16,420.80 ",IP,"4,660.01","16,420.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Medical/Surgical,Relative Weights,"$52,288.00 ",IP,"4,660.01","52,288.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Medical/Surgical,Relative Weights,"$13,832.00 ",IP,"4,660.01","13,832.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-881,DEPRESSIVE NEUROSES,Medical/Surgical,Relative Weights,"$12,832.00 ",IP,"4,660.01","12,832.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Medical/Surgical,Relative Weights,"$13,177.60 ",IP,"4,660.01","13,177.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-883,DISORDERS OF PERSONALITY AND IMPULSE CONTROL,Medical/Surgical,Relative Weights,"$25,308.80 ",IP,"4,660.01","25,308.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Medical/Surgical,Relative Weights,"$23,156.80 ",IP,"4,660.01","23,156.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-885,PSYCHOSES,Medical/Surgical,Relative Weights,"$19,830.40 ",IP,"4,660.01","19,830.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Medical/Surgical,Relative Weights,"$19,579.20 ",IP,"4,660.01","19,579.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Medical/Surgical,Relative Weights,"$17,276.80 ",IP,"4,660.01","17,276.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Medical/Surgical,Relative Weights,"$8,784.00 ",IP,"4,660.01","8,784.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Medical/Surgical,Relative Weights,"$25,587.20 ",IP,"4,660.01","25,587.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-896,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Medical/Surgical,Relative Weights,"$28,484.80 ",IP,"4,660.01","28,484.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-897,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC,Medical/Surgical,Relative Weights,"$13,232.00 ",IP,"4,660.01","13,232.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Medical/Surgical,Relative Weights,"$68,299.20 ",IP,"4,660.01","68,299.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Medical/Surgical,Relative Weights,"$31,428.80 ",IP,"4,660.01","31,428.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,164.80 ",IP,"4,660.01","18,164.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Medical/Surgical,Relative Weights,"$59,632.00 ",IP,"4,660.01","59,632.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$26,400.00 ",IP,"4,660.01","26,400.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Medical/Surgical,Relative Weights,"$28,860.80 ",IP,"4,660.01","28,860.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Medical/Surgical,Relative Weights,"$63,171.20 ",IP,"4,660.01","63,171.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Medical/Surgical,Relative Weights,"$32,806.40 ",IP,"4,660.01","32,806.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$21,936.00 ",IP,"4,660.01","21,936.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical/Surgical,Relative Weights,"$26,217.60 ",IP,"4,660.01","26,217.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical/Surgical,Relative Weights,"$14,190.40 ",IP,"4,660.01","14,190.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical/Surgical,Relative Weights,"$27,192.00 ",IP,"4,660.01","27,192.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical/Surgical,Relative Weights,"$10,534.40 ",IP,"4,660.01","10,534.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-917,POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,Medical/Surgical,Relative Weights,"$23,656.00 ",IP,"4,660.01","23,656.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-918,POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,665.60 ",IP,"4,660.01","12,665.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical/Surgical,Relative Weights,"$29,505.60 ",IP,"4,660.01","29,505.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical/Surgical,Relative Weights,"$16,393.60 ",IP,"4,660.01","16,393.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,166.40 ",IP,"4,660.01","11,166.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical/Surgical,Relative Weights,"$25,411.20 ",IP,"4,660.01","25,411.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical/Surgical,Relative Weights,"$15,036.80 ",IP,"4,660.01","15,036.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Medical/Surgical,Relative Weights,"$337,460.80 ",IP,"4,660.01","337,460.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Medical/Surgical,Relative Weights,"$104,505.60 ",IP,"4,660.01","104,505.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$48,222.40 ",IP,"4,660.01","48,222.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical/Surgical,Relative Weights,"$36,206.40 ",IP,"4,660.01","36,206.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical/Surgical,Relative Weights,"$31,054.40 ",IP,"4,660.01","31,054.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-935,NON-EXTENSIVE BURNS,Medical/Surgical,Relative Weights,"$30,926.40 ",IP,"4,660.01","30,926.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Medical/Surgical,Relative Weights,"$53,993.60 ",IP,"4,660.01","53,993.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Medical/Surgical,Relative Weights,"$35,534.40 ",IP,"4,660.01","35,534.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-941,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$30,769.60 ",IP,"4,660.01","30,769.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-945,REHABILITATION WITH CC/MCC,Medical/Surgical,Relative Weights,"$23,710.40 ",IP,"4,660.01","23,710.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$18,019.20 ",IP,"4,660.01","18,019.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical/Surgical,Relative Weights,"$19,104.00 ",IP,"4,660.01","19,104.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical/Surgical,Relative Weights,"$12,593.60 ",IP,"4,660.01","12,593.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical/Surgical,Relative Weights,"$17,758.40 ",IP,"4,660.01","17,758.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$11,843.20 ",IP,"4,660.01","11,843.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical/Surgical,Relative Weights,"$8,953.60 ",IP,"4,660.01","8,953.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Medical/Surgical,Relative Weights,"$100,628.80 ",IP,"4,660.01","100,628.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Medical/Surgical,Relative Weights,"$61,600.00 ",IP,"4,660.01","61,600.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical/Surgical,Relative Weights,"$118,734.40 ",IP,"4,660.01","118,734.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical/Surgical,Relative Weights,"$67,291.20 ",IP,"4,660.01","67,291.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$43,777.60 ",IP,"4,660.01","43,777.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical/Surgical,Relative Weights,"$43,678.40 ",IP,"4,660.01","43,678.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical/Surgical,Relative Weights,"$23,868.80 ",IP,"4,660.01","23,868.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$14,600.00 ",IP,"4,660.01","14,600.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Medical/Surgical,Relative Weights,"$93,630.40 ",IP,"4,660.01","93,630.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Medical/Surgical,Relative Weights,"$47,819.20 ",IP,"4,660.01","47,819.20",,,,,,,,,,,,
Aetna Commercial,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical/Surgical,Relative Weights,"$43,048.00 ",IP,"4,660.01","43,048.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical/Surgical,Relative Weights,"$20,513.60 ",IP,"4,660.01","20,513.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$15,193.60 ",IP,"4,660.01","15,193.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical/Surgical,Relative Weights,"$21,188.80 ",IP,"4,660.01","21,188.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,"$73,832.00 ",IP,"4,660.01","73,832.00",,,,,,,,,,,,
Aetna Commercial,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Medical/Surgical,Relative Weights,"$40,585.60 ",IP,"4,660.01","40,585.60",,,,,,,,,,,,
Aetna Commercial,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$26,436.80 ",IP,"4,660.01","26,436.80",,,,,,,,,,,,
Aetna Commercial,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Medical/Surgical,Relative Weights,"$52,414.40 ",IP,"4,660.01","52,414.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Medical/Surgical,Relative Weights,"$27,302.40 ",IP,"4,660.01","27,302.40",,,,,,,,,,,,
Aetna Commercial,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Medical/Surgical,Relative Weights,"$17,977.60 ",IP,"4,660.01","17,977.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","463,441.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","254,896.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","303,857.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","189,792.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","163,572.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","75,067.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-007,LUNG TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","185,188.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,828.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-010,PANCREAS TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,883.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,262.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,310.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-013,TRACHEOSTOMY FOR FACE - MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,528.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","204,460.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","107,619.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,283.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","597,264.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","106,590.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","165,121.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","120,505.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,753.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,596.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,920.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","71,867.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,928.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,188.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","93,120.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,720.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,713.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,857.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,395.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,531.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,593.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,393.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,619.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,395.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,516.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,224.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,324.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,617.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,158.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,521.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,177.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,852.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,694.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,996.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,227.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,787.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,024.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,649.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-061,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,211.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-062,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,795.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,358.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,608.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,291.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,374.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,793.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,217.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,577.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,822.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,172.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,339.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,190.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,294.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,016.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,694.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,510.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,184.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,628.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,472.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,352.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,129.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,467.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,467.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,902.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,366.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,801.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-088,CONCUSSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,348.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-089,CONCUSSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,979.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,676.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,382.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,777.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,500.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,129.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,128.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,304.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,041.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,774.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,356.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-100,SEIZURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,977.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-101,SEIZURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,192.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-102,HEADACHES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,427.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-103,HEADACHES W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,251.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,068.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,128.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,252.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,035.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,622.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,019.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,300.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,244.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,380.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,366.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,249.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,088.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,497.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,489.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-139,SALIVARY GLAND PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,628.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,689.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,320.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,740.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,420.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,008.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-145,OTHER EAR - NOSE - MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,416.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,529.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,817.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,580.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-149,DYSEQUILIBRIUM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,768.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-150,EPISTAXIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,195.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-151,EPISTAXIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,792.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,230.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,369.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,680.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,508.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-156,OTHER EAR - NOSE - MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,521.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,158.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,225.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,492.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","79,377.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,227.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,617.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,660.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,790.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,905.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,707.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,187.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,524.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,294.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,937.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,804.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,934.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,600.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,889.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,630.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,377.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,691.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-187,PLEURAL EFFUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,515.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,649.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,596.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,982.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,129.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,118.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,971.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,808.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,640.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,777.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,089.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,876.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-199,PNEUMOTHORAX WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,601.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-200,PNEUMOTHORAX WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,200.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,352.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,449.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,288.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,680.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,916.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,147.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,622.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,676.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","178,526.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","166,881.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","103,884.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,291.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","128,881.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,398.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,836.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","134,737.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","99,393.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","117,795.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,028.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","105,788.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","84,030.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","99,444.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,808.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","135,843.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","94,372.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","124,683.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,078.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","96,483.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","65,292.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","76,939.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,638.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,462.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,560.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,521.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,051.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-245,AICD GENERATOR PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,624.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,011.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,811.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,782.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,068.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,364.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,556.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,131.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,459.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,952.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,688.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,289.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,576.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,220.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,923.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,347.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,860.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,329.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-263,VEIN LIGATION AND STRIPPING,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,884.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,964.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-265,AICD LEAD PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,803.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","113,555.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","89,614.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","111,273.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,033.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,905.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,033.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,020.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,395.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,566.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,019.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,913.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,608.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,833.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,747.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","7,942.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,425.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI - WITH CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,400.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,896.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,281.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,377.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,454.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,321.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,441.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,513.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,700.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,516.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,273.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","7,811.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,502.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,675.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,880.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,496.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,822.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-304,HYPERTENSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,529.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-305,HYPERTENSION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,816.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,059.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,894.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,188.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,990.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,934.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-311,ANGINA PECTORIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,152.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-312,SYNCOPE AND COLLAPSE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,395.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-313,CHEST PAIN,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,532.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,334.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,603.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,992.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,052.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,099.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,043.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","41,753.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,648.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,604.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,624.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,361.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-332,RECTAL RESECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","66,555.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-333,RECTAL RESECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,256.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,747.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,246.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,526.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,121.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,780.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,120.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,654.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,059.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,929.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,750.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,814.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,243.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,400.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,385.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,478.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,668.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,238.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,846.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,648.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,132.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,528.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,747.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,662.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,059.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,424.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,076.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,228.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,961.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,652.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,441.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,896.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,086.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,278.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,323.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,782.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,891.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,193.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,129.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,955.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,292.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,974.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,278.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,905.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,896.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,416.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,188.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,148.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,321.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,910.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,230.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,457.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,017.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,395.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,688.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-406,PANCREAS - LIVER AND SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,032.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-407,PANCREAS - LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,856.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,992.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,828.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,051.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,038.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,411.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,702.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,008.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,510.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,755.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,776.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,009.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,043.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","56,225.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,542.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,222.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","66,864.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,505.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,692.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,113.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,456.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,913.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,044.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,923.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,312.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,540.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,510.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,694.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,139.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,905.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,604.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,700.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,228.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,059.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","147,097.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","97,569.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","76,656.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","137,569.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","104,032.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,278.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","107,708.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,923.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","97,219.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,307.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,846.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,592.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,497.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,520.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,219.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,864.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","49,350.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,398.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,268.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,851.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,643.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","65,164.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,097.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,556.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,710.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,710.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,948.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,392.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,528.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,348.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,180.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","54,521.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,374.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,244.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,593.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,771.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","55,491.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,203.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,630.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,147.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,769.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,339.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","41,348.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,179.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,462.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,920.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,292.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-503,FOOT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,059.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-504,FOOT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,382.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,382.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,611.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,356.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,624.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-509,ARTHROSCOPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,780.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,691.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,496.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,899.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,944.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-514,HAND OR WRIST PROCEDURES - EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,907.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,192.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,377.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,347.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,348.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,323.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,678.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","49,014.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,025.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,601.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,617.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,740.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,345.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,931.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,542.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-539,OSTEOMYELITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,059.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-540,OSTEOMYELITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,724.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,449.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,884.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,692.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,419.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,992.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,305.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,328.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,473.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-549,SEPTIC ARTHRITIS W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,950.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,123.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,969.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,072.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,292.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,646.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,804.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,900.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-557,TENDONITIS - MYOSITIS AND BURSITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,302.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,732.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,886.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,222.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,657.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,528.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,932.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,220.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,100.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,024.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","45,380.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,124.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,641.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","88,596.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,944.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,184.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,961.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,758.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,515.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,844.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,649.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,158.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,265.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,665.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,284.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,876.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-592,SKIN ULCERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,987.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-593,SKIN ULCERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,188.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,099.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,193.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,827.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,187.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,779.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,739.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,931.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,001.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-602,CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,985.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-603,CELLULITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,516.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-604,TRAUMA TO THE SKIN - SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,860.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,547.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,176.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,209.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,188.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,185.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,820.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,545.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,848.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,977.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,177.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,542.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,804.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE - NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,966.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,508.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","45,459.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-626,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,436.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-627,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,908.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,169.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,548.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,510.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-637,DIABETES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,995.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-638,DIABETES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,070.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-639,DIABETES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,748.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,644.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,048.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,600.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,612.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,292.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,284.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,209.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,097.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-652,KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,910.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","87,187.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,403.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,281.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,507.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,945.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,265.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,636.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,094.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,030.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,876.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,518.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,947.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-665,PROSTATECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,587.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-666,PROSTATECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,748.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,918.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,081.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,510.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,624.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,427.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,414.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","55,409.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,086.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,032.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-682,RENAL FAILURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,523.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-683,RENAL FAILURE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,049.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,720.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,971.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,764.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,964.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,780.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,675.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-693,URINARY STONES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,300.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-694,URINARY STONES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,668.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,180.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,035.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-697,URETHRAL STRICTURE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,952.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,707.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,403.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,916.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,729.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,862.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,990.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,598.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,084.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,920.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,865.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,856.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,302.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,424.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,776.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,779.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,344.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,425.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,390.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,510.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,892.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,689.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,856.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,076.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,051.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-734,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,564.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-735,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,616.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,131.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,931.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,625.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,147.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,800.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,472.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,472.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,116.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,704.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,728.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-746,VAGINA - CERVIX AND VULVA PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,750.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,008.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,572.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,318.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,454.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,136.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,041.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,657.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,353.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,472.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,931.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,761.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,440.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,732.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,926.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,209.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,300.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-779,ABORTION WITHOUT D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,646.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,963.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,518.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,644.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,457.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,003.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,193.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Acute Care,Per Diem,"$5,358.42 ",IP,600,"27,496.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Acute Care,Per Diem,"$5,358.42 ",IP,600,"90,673.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"61,926.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"37,364.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"63,611.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"22,515.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-795,NORMAL NEWBORN,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,086.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,718.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,236.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-799,SPLENECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,302.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-800,SPLENECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,222.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,936.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,339.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,156.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,827.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,428.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,742.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,257.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,846.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,547.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,371.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,041.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,075.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-813,COAGULATION DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,715.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,251.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,880.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,574.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,828.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,064.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,966.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,996.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,481.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,025.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","71,953.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,803.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,411.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,588.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,961.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,843.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,291.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,624.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,937.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,476.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,576.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","96,801.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,819.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,713.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,185.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,140.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,780.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,451.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,932.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,524.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,446.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,888.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,558.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,718.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,363.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,464.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-849,RADIOTHERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,800.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","79,113.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,510.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,920.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,731.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,555.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,574.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,060.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,638.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,000.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-865,VIRAL ILLNESS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,662.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,395.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,672.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,934.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,616.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","102,796.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,891.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,345.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,180.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Acute Care,Per Diem,"$5,358.42 ",IP,550,"13,817.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-881,DEPRESSIVE NEUROSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"12,822.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Acute Care,Per Diem,"$5,358.42 ",IP,550,"13,168.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Acute Care,Per Diem,"$5,358.42 ",IP,550,"25,252.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Acute Care,Per Diem,"$5,358.42 ",IP,550,"23,100.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-885,PSYCHOSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"19,793.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,550,"19,544.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"17,259.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,760.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,472.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-896,ALCOHOL - DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,432.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,208.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,195.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,398.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,150.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,542.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,345.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,700.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,313.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,646.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,993.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,182.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,217.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,161.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,516.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,640.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,657.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,350.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,436.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,062.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,401.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,886.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","336,494.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","104,419.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,142.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,121.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,044.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-935,NON-EXTENSIVE BURNS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,932.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","54,179.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,481.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,795.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-945,REHABILITATION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,755.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,035.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,041.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,569.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-949,AFTERCARE WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,713.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,822.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,931.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","100,608.00",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,580.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","118,732.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","67,286.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,747.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,587.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,814.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,606.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","92,598.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,121.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,971.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,465.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,185.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,132.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","73,724.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,659.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,476.80",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,193.60",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,891.20",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,854.40",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
Aetna Better Health Duals,DRG,MS-999,UNGROUPABLE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
Aetna Better Health Duals,ExceptPatType,14,,Swing Bed,Per Diem,"$4,816.25 ",IP,640,"4,816.25",,,,,,,,,,,,
Aetna Better Health Duals,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,94.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,8.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,7.01,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,47.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,8.68,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,47.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,16.38,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,13.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,16.59,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,60,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,16.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,16.13,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,11.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,12.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,17.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,32.62,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,86.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,78.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,125.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,80.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,801.62,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,51.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,55.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,209.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,43.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,579.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,161.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,46.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,50.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,148.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,66.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,129.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,165.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,285.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,103,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,91.16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,50.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,67.21,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,4.02,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,3.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,3.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,2.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,2.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,4.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,3.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,260.5,260.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,897,897,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,68.92,68.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,54.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,"1,487.37","1,487.37",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,55.54,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,153.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,69.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Aetna Better Health Duals,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,16.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,38.62,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,25.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,7.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,6.23,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,30,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,40.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,16.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,25.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,13.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,22.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,19.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,9.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,6.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,25.55,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,20.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,21.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,18.97,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,15.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,16.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,17.12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,26.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,4.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,4.38,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,5.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,15.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,23.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,26.79,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,13.68,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,6.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,4.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,12.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,14.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,18.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,9.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,27.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,29.08,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,25.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,14.12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,12.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,4.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,4.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,7.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,20.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,20.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,27.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,18.68,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,12.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,22.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,16.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,4.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,24.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,6.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,11.55,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,11.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,5.12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,9.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,25.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,22.23,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,38.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,22.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,61.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,18.79,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,32.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,21.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,24.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,24.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,14.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,26.24,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,22.97,22.97,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,19.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,13.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,18.54,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,14.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,17.34,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,11.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,21.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,9.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,16.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,8.02,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,78.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,17.69,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,17.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,14.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,17.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,5.04,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,3.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,9.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,13.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,15.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Aetna Better Health Duals,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,16.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,18.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,16.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,12.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,26.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,7.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,20.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,21.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,6.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,8.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,29.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,17.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,22.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,27.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,22.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,24.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,18.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,11.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,19.82,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,8.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,8.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,12.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,6.04,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,12.79,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,19.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,20.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,11.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,19.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,46.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,12.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,10.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,6.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,26.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,16.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,17.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,12.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,13.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,24.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,27.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,23.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,21.21,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,29.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,14.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,41.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,3.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,7.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,8.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,16.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,10.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,4.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,8.44,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,14.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,4.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,4.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,14.59,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,21.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,21.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,20.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,22.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,20.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,19.38,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,5.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,17.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,29.21,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,14.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,26.69,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,28.1,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,14.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,87.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,64.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,71.23,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,36.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,25.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,21.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,25.21,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,4.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,5.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,4.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,21.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,18.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,8.1,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,5.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,25.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,21.23,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,16.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,6.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,9.02,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,5.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,12.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,15.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,12.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,9.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,10.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,10.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,5.13,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,5.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,5.08,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,4.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,17.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,13.72,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,17.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,12.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,11.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,12.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,4.82,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,3.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,5.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,3.02,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,2.54,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,4.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,35.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,11.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,20.37,20.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,12.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,20.42,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,19.04,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,9.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,11.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,10.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,13.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,4.28,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,4.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,80.46,80.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,12.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,15.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,4.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,9.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,8.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,11.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,6.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,18.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,24.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,4.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,3.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,9.58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,9.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,2.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,5.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,6.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,9.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,11.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,7.82,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,5.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,18.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,11.16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,8.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,20.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,10.01,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,25.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,14.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,23.13,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,24.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,22.34,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,29.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,15.59,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,21.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,23.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,10.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,49.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,46.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,77.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,14.55,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,16.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,11.54,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,10.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,6.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,5.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,61.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,4.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,13.38,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,11.82,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,12.68,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,11.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,12.12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,15.21,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,13.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,18.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,14.16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,13.01,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,9.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,17.16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,13.79,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,8.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,13.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,13.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,11.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,13.55,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,16.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,15.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,18.23,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,24.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,14.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,15.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,14.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,189.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,47.59,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,78.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,29.68,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,106.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,36.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,8.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,16.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,6.68,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,8.62,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,6.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,27.07,27.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,8.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,20.46,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,15.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,19.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,10.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,14.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,11.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,8.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,7.48,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,40.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,15.02,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,5.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,19.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,20.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,15.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,16.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,60.8,60.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,12.18,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,16.1,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,13.82,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,14.38,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,21.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,14.13,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,13.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,16.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,10.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,55.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,22.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,53.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,31.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,29.8,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,85.1,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,58.62,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,48.24,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,41.68,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,27.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,302.62,302.62,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,40.55,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,43.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,12.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,16.55,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,32.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,13.1,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,21.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,35.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,24.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,16.53,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,130.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,12.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,7.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,23.04,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,50.56,50.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,27.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,24.03,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,14.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,42.22,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,25.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,26.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,116.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,140.73,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,150.3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,143.75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,147.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,13.07,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,264.34,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,125.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,150.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,144.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,188.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,173.66,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,21.42,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,40.7,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,34.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,42.38,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,51.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,33.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,26.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,34.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,4.72,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,5.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,7.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,4.85,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,5.79,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,9.84,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,12.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,10.38,,,,,,,,,,,,
Aetna Better Health Duals,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,,,,,,,
Aetna Better Health Duals,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,6.5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,19.31,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,27.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,43.97,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,26.49,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,31.94,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Aetna Better Health Duals,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Aetna Better Health Duals,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
Aetna Better Health Duals,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Aetna Better Health Duals,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,5.83,,,,,,,,,,,,
Aetna Better Health Duals,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Aetna Better Health Duals,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
Aetna Better Health Duals,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Aetna Better Health Duals,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
Aetna Better Health Duals,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Aetna Better Health Duals,,,,All Other,Straight Discount,30.00%,OP,,,,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,11,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$38,043.18 ",IP,"38,043.18","38,043.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,12,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$40,281.56 ",IP,"40,281.56","40,281.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,13,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$42,053.29 ",IP,"42,053.29","42,053.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,14,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$78,175.26 ",IP,"78,175.26","78,175.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,21,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$45,599.51 ",IP,"45,599.51","45,599.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,22,HEART &/OR LUNG TRANSPLANT,,Relative Weights,"$58,026.75 ",IP,"58,026.75","58,026.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,23,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$74,400.53 ",IP,"74,400.53","74,400.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,24,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$107,953.54 ",IP,"107,953.54","107,953.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,41,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$33,014.21 ",IP,"33,014.21","33,014.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,42,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$37,820.51 ",IP,"37,820.51","37,820.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,43,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$49,052.96 ",IP,"49,052.96","49,052.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,44,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$72,921.22 ",IP,"72,921.22","72,921.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,51,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$23,684.08 ",IP,"23,684.08","23,684.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,52,TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,,Relative Weights,"$26,315.91 ",IP,"26,315.91","26,315.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,53,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$36,197.91 ",IP,"36,197.91","36,197.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,54,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$48,934.75 ",IP,"48,934.75","48,934.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,61,PANCREAS TRANSPLANT,,Relative Weights,"$40,520.03 ",IP,"40,520.03","40,520.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,62,PANCREAS TRANSPLANT,,Relative Weights,"$45,022.22 ",IP,"45,022.22","45,022.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,63,PANCREAS TRANSPLANT,,Relative Weights,"$47,794.94 ",IP,"47,794.94","47,794.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,64,PANCREAS TRANSPLANT,,Relative Weights,"$66,459.33 ",IP,"66,459.33","66,459.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,71,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$38,434.91 ",IP,"38,434.91","38,434.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,72,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$48,059.19 ",IP,"48,059.19","48,059.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,73,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$59,827.69 ",IP,"59,827.69","59,827.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,74,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$99,672.84 ",IP,"99,672.84","99,672.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,81,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$22,091.37 ",IP,"22,091.37","22,091.37",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,82,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$27,118.96 ",IP,"27,118.96","27,118.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,83,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$32,175.76 ",IP,"32,175.76","32,175.76",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,84,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$51,576.54 ",IP,"51,576.54","51,576.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,91,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$27,699.69 ",IP,"27,699.69","27,699.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,92,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$30,776.86 ",IP,"30,776.86","30,776.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,93,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$36,358.72 ",IP,"36,358.72","36,358.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,94,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$79,300.63 ",IP,"79,300.63","79,300.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,101,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$4,104.27 ",IP,"4,104.27","4,104.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,102,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,103,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$12,592.86 ",IP,"12,592.86","12,592.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,104,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$37,584.09 ",IP,"37,584.09","37,584.09",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,201,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$9,991.61 ",IP,"9,991.61","9,991.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,202,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$11,868.15 ",IP,"11,868.15","11,868.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,203,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$16,002.32 ",IP,"16,002.32","16,002.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,204,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$28,673.87 ",IP,"28,673.87","28,673.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,211,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$9,882.68 ",IP,"9,882.68","9,882.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,212,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$13,243.69 ",IP,"13,243.69","13,243.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,213,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$18,834.48 ",IP,"18,834.48","18,834.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,214,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$27,671.86 ",IP,"27,671.86","27,671.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,221,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$6,449.86 ",IP,"6,449.86","6,449.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,222,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$7,492.76 ",IP,"7,492.76","7,492.76",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,223,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$10,628.01 ",IP,"10,628.01","10,628.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,224,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$25,450.32 ",IP,"25,450.32","25,450.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,231,SPINAL PROCEDURES,,Relative Weights,"$7,646.71 ",IP,"7,646.71","7,646.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,232,SPINAL PROCEDURES,,Relative Weights,"$9,630.12 ",IP,"9,630.12","9,630.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,233,SPINAL PROCEDURES,,Relative Weights,"$16,000.26 ",IP,"16,000.26","16,000.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,234,SPINAL PROCEDURES,,Relative Weights,"$29,075.91 ",IP,"29,075.91","29,075.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,241,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$5,741.65 ",IP,"5,741.65","5,741.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,242,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$6,726.14 ",IP,"6,726.14","6,726.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,243,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$13,747.79 ",IP,"13,747.79","13,747.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,244,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$24,782.31 ",IP,"24,782.31","24,782.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,261,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,157.39 ",IP,"7,157.39","7,157.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,262,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$8,935.31 ",IP,"8,935.31","8,935.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,263,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$12,455.76 ",IP,"12,455.76","12,455.76",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,264,OTHER NERVOUS SYSTEM & RELATED PROCEDURES,,Relative Weights,"$22,781.03 ",IP,"22,781.03","22,781.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,401,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,482.55 ",IP,"5,482.55","5,482.55",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,402,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,877.72 ",IP,"5,877.72","5,877.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,403,SPINAL DISORDERS and INJURIES,,Relative Weights,"$8,545.98 ",IP,"8,545.98","8,545.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,404,SPINAL DISORDERS and INJURIES,,Relative Weights,"$17,945.87 ",IP,"17,945.87","17,945.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,411,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,340.00 ",IP,"4,340.00","4,340.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,412,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,441.02 ",IP,"4,441.02","4,441.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,413,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$5,802.81 ",IP,"5,802.81","5,802.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,414,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$8,029.51 ",IP,"8,029.51","8,029.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,421,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,328.02 ",IP,"3,328.02","3,328.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,422,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,814.25 ",IP,"3,814.25","3,814.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,423,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$5,381.53 ",IP,"5,381.53","5,381.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,424,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$12,544.07 ",IP,"12,544.07","12,544.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,431,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$4,040.70 ",IP,"4,040.70","4,040.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,432,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$5,014.88 ",IP,"5,014.88","5,014.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,433,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$7,268.72 ",IP,"7,268.72","7,268.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,434,MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,,Relative Weights,"$15,032.61 ",IP,"15,032.61","15,032.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,441,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$3,968.19 ",IP,"3,968.19","3,968.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,442,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$4,927.25 ",IP,"4,927.25","4,927.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,443,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$6,702.77 ",IP,"6,702.77","6,702.77",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,444,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$9,326.01 ",IP,"9,326.01","9,326.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,451,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$3,612.20 ",IP,"3,612.20","3,612.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,452,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$4,429.34 ",IP,"4,429.34","4,429.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,453,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$5,951.60 ",IP,"5,951.60","5,951.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,454,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$10,976.10 ",IP,"10,976.10","10,976.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,461,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$3,784.70 ",IP,"3,784.70","3,784.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,462,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$4,264.40 ",IP,"4,264.40","4,264.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,463,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$5,292.53 ",IP,"5,292.53","5,292.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,464,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$10,621.82 ",IP,"10,621.82","10,621.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,471,TRANSIENT ISCHEMIA,,Relative Weights,"$3,321.15 ",IP,"3,321.15","3,321.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,472,TRANSIENT ISCHEMIA,,Relative Weights,"$3,597.42 ",IP,"3,597.42","3,597.42",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,473,TRANSIENT ISCHEMIA,,Relative Weights,"$4,242.41 ",IP,"4,242.41","4,242.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,474,TRANSIENT ISCHEMIA,,Relative Weights,"$7,719.21 ",IP,"7,719.21","7,719.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,481,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,400.87 ",IP,"3,400.87","3,400.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,482,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,627.32 ",IP,"3,627.32","3,627.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,483,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$4,545.48 ",IP,"4,545.48","4,545.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,484,"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,491,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$5,943.01 ",IP,"5,943.01","5,943.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,492,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$9,716.03 ",IP,"9,716.03","9,716.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,493,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$11,066.13 ",IP,"11,066.13","11,066.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,494,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$20,732.33 ",IP,"20,732.33","20,732.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,501,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$3,211.53 ",IP,"3,211.53","3,211.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,502,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$6,688.34 ",IP,"6,688.34","6,688.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,503,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$10,165.49 ",IP,"10,165.49","10,165.49",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,504,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,511,VIRAL MENINGITIS,,Relative Weights,"$2,048.35 ",IP,"2,048.35","2,048.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,512,VIRAL MENINGITIS,,Relative Weights,"$3,205.00 ",IP,"3,205.00","3,205.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,513,VIRAL MENINGITIS,,Relative Weights,"$5,993.52 ",IP,"5,993.52","5,993.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,514,VIRAL MENINGITIS,,Relative Weights,"$12,441.32 ",IP,"12,441.32","12,441.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,521,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,101.91 ",IP,"3,101.91","3,101.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,522,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,492.61 ",IP,"3,492.61","3,492.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,523,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$4,423.15 ",IP,"4,423.15","4,423.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,524,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$9,303.33 ",IP,"9,303.33","9,303.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,531,SEIZURE,,Relative Weights,"$2,710.87 ",IP,"2,710.87","2,710.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,532,SEIZURE,,Relative Weights,"$3,311.87 ",IP,"3,311.87","3,311.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,533,SEIZURE,,Relative Weights,"$4,410.44 ",IP,"4,410.44","4,410.44",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,534,SEIZURE,,Relative Weights,"$10,918.03 ",IP,"10,918.03","10,918.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,541,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$2,681.66 ",IP,"2,681.66","2,681.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,542,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,180.26 ",IP,"3,180.26","3,180.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,543,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,544,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$6,681.46 ",IP,"6,681.46","6,681.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,551,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$3,376.47 ",IP,"3,376.47","3,376.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,552,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$4,570.57 ",IP,"4,570.57","4,570.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,553,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$6,561.54 ",IP,"6,561.54","6,561.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,554,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$13,008.65 ",IP,"13,008.65","13,008.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,561,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$3,264.10 ",IP,"3,264.10","3,264.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,562,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$4,370.58 ",IP,"4,370.58","4,370.58",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,563,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$6,249.87 ",IP,"6,249.87","6,249.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,564,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$13,974.93 ",IP,"13,974.93","13,974.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,571,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,572,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$3,996.71 ",IP,"3,996.71","3,996.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,573,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$5,550.25 ",IP,"5,550.25","5,550.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,574,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$10,437.98 ",IP,"10,437.98","10,437.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,581,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$3,385.75 ",IP,"3,385.75","3,385.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,582,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$4,062.35 ",IP,"4,062.35","4,062.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,583,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$5,313.15 ",IP,"5,313.15","5,313.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,584,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$10,386.78 ",IP,"10,386.78","10,386.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,591,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$3,746.90 ",IP,"3,746.90","3,746.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,592,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$4,463.01 ",IP,"4,463.01","4,463.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,593,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$6,809.98 ",IP,"6,809.98","6,809.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,594,ANOXIC & OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$11,699.43 ",IP,"11,699.43","11,699.43",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,731,ORBIT AND EYE PROCEDURES,,Relative Weights,"$5,014.53 ",IP,"5,014.53","5,014.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,732,ORBIT AND EYE PROCEDURES,,Relative Weights,"$6,421.34 ",IP,"6,421.34","6,421.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,733,ORBIT AND EYE PROCEDURES,,Relative Weights,"$9,718.43 ",IP,"9,718.43","9,718.43",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,734,ORBIT AND EYE PROCEDURES,,Relative Weights,"$22,403.73 ",IP,"22,403.73","22,403.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,821,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$2,633.21 ",IP,"2,633.21","2,633.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,822,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$3,410.83 ",IP,"3,410.83","3,410.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,823,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$4,809.73 ",IP,"4,809.73","4,809.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,824,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$13,027.89 ",IP,"13,027.89","13,027.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,891,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$9,059.01 ",IP,"9,059.01","9,059.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,892,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$11,457.52 ",IP,"11,457.52","11,457.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,893,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$17,804.98 ",IP,"17,804.98","17,804.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,894,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$32,041.75 ",IP,"32,041.75","32,041.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,911,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$6,729.57 ",IP,"6,729.57","6,729.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,912,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$9,964.47 ",IP,"9,964.47","9,964.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,913,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$16,613.29 ",IP,"16,613.29","16,613.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,914,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$32,825.56 ",IP,"32,825.56","32,825.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,921,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$6,039.23 ",IP,"6,039.23","6,039.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,922,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$8,191.36 ",IP,"8,191.36","8,191.36",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,923,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$13,246.44 ",IP,"13,246.44","13,246.44",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,924,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$30,839.40 ",IP,"30,839.40","30,839.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,951,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,246.53 ",IP,"4,246.53","4,246.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,952,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,953,CLEFT LIP & PALATE REPAIR,,Relative Weights,"$7,436.75 ",IP,"7,436.75","7,436.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,954,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$14,987.25 ",IP,"14,987.25","14,987.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,971,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$2,853.47 ",IP,"2,853.47","2,853.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,972,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$3,981.59 ",IP,"3,981.59","3,981.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,973,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$6,406.56 ",IP,"6,406.56","6,406.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,974,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$15,100.30 ",IP,"15,100.30","15,100.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,981,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$4,806.30 ",IP,"4,806.30","4,806.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,982,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$6,289.73 ",IP,"6,289.73","6,289.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,983,"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",,Relative Weights,"$10,153.46 ",IP,"10,153.46","10,153.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,984,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$19,630.32 ",IP,"19,630.32","19,630.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1101,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,539.30 ",IP,"4,539.30","4,539.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1102,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,571.26 ",IP,"4,571.26","4,571.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1103,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$6,424.43 ",IP,"6,424.43","6,424.43",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1104,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$10,388.84 ",IP,"10,388.84","10,388.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1111,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,014.97 ",IP,"3,014.97","3,014.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1112,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,232.83 ",IP,"3,232.83","3,232.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1113,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,830.06 ",IP,"3,830.06","3,830.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1114,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$5,856.07 ",IP,"5,856.07","5,856.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1131,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$1,710.57 ",IP,"1,710.57","1,710.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1132,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$2,449.71 ",IP,"2,449.71","2,449.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1133,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$3,709.10 ",IP,"3,709.10","3,709.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1134,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$7,363.91 ",IP,"7,363.91","7,363.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1141,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$2,233.23 ",IP,"2,233.23","2,233.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1142,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$3,024.94 ",IP,"3,024.94","3,024.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1143,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$4,392.57 ",IP,"4,392.57","4,392.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1144,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$11,476.08 ",IP,"11,476.08","11,476.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1151,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$2,472.39 ",IP,"2,472.39","2,472.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1152,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$3,380.25 ",IP,"3,380.25","3,380.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1153,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$4,829.66 ",IP,"4,829.66","4,829.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1154,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$10,560.66 ",IP,"10,560.66","10,560.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1201,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,978.60 ",IP,"8,978.60","8,978.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1202,MAJOR RESPIRATORY & CHEST PROCEDURES,,Relative Weights,"$10,724.22 ",IP,"10,724.22","10,724.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1203,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$15,096.86 ",IP,"15,096.86","15,096.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1204,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$30,187.20 ",IP,"30,187.20","30,187.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1211,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$6,647.79 ",IP,"6,647.79","6,647.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1212,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,066.62 ",IP,"8,066.62","8,066.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1213,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$12,267.10 ",IP,"12,267.10","12,267.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1214,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$23,708.13 ",IP,"23,708.13","23,708.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1301,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$15,152.88 ",IP,"15,152.88","15,152.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1302,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,,Relative Weights,"$17,209.82 ",IP,"17,209.82","17,209.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1303,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$20,315.17 ",IP,"20,315.17","20,315.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1304,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$28,326.47 ",IP,"28,326.47","28,326.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1311,CYSTIC FIBROSIS PULMONARY DISEASE,,Relative Weights,"$6,540.23 ",IP,"6,540.23","6,540.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1312,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$9,797.46 ",IP,"9,797.46","9,797.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1313,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$13,253.65 ",IP,"13,253.65","13,253.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1314,CYSTIC FIBROSIS PULMONARY DISEASE,,Relative Weights,"$17,241.78 ",IP,"17,241.78","17,241.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1321,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$2,377.20 ",IP,"2,377.20","2,377.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1322,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$3,157.24 ",IP,"3,157.24","3,157.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1323,BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$5,204.90 ",IP,"5,204.90","5,204.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1324,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$9,706.75 ",IP,"9,706.75","9,706.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1331,RESPIRATORY FAILURE,,Relative Weights,"$2,072.41 ",IP,"2,072.41","2,072.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1332,RESPIRATORY FAILURE,,Relative Weights,"$3,703.26 ",IP,"3,703.26","3,703.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1333,RESPIRATORY FAILURE,,Relative Weights,"$5,064.70 ",IP,"5,064.70","5,064.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1334,RESPIRATORY FAILURE,,Relative Weights,"$9,349.38 ",IP,"9,349.38","9,349.38",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1341,PULMONARY EMBOLISM,,Relative Weights,"$2,977.18 ",IP,"2,977.18","2,977.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1342,PULMONARY EMBOLISM,,Relative Weights,"$3,832.12 ",IP,"3,832.12","3,832.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1343,PULMONARY EMBOLISM,,Relative Weights,"$5,276.03 ",IP,"5,276.03","5,276.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1344,PULMONARY EMBOLISM,,Relative Weights,"$8,166.27 ",IP,"8,166.27","8,166.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1351,MAJOR CHEST and RESPIRAZORY TRAUMA,,Relative Weights,"$3,792.26 ",IP,"3,792.26","3,792.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1352,MAJOR CHEST & RESPIRATORY TRAUMA,,Relative Weights,"$3,955.48 ",IP,"3,955.48","3,955.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1353,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$5,683.92 ",IP,"5,683.92","5,683.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1354,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$10,178.89 ",IP,"10,178.89","10,178.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1361,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,244.47 ",IP,"4,244.47","4,244.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1362,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,742.73 ",IP,"4,742.73","4,742.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1363,RESPIRATORY MALIGNANCY,,Relative Weights,"$6,049.19 ",IP,"6,049.19","6,049.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1364,RESPIRATORY MALIGNANCY,,Relative Weights,"$9,049.05 ",IP,"9,049.05","9,049.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1371,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,151.74 ",IP,"3,151.74","3,151.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1372,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,930.39 ",IP,"3,930.39","3,930.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1373,MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,,Relative Weights,"$5,471.90 ",IP,"5,471.90","5,471.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1374,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$8,758.68 ",IP,"8,758.68","8,758.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1381,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$1,796.82 ",IP,"1,796.82","1,796.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1382,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$2,575.82 ",IP,"2,575.82","2,575.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1383,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$4,712.83 ",IP,"4,712.83","4,712.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1384,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$9,865.85 ",IP,"9,865.85","9,865.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1391,OTHER PNEUMONIA,,Relative Weights,"$2,182.71 ",IP,"2,182.71","2,182.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1392,OTHER PNEUMONIA,,Relative Weights,"$3,016.35 ",IP,"3,016.35","3,016.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1393,OTHER PNEUMONIA,,Relative Weights,"$4,342.75 ",IP,"4,342.75","4,342.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1394,OTHER PNEUMONIA,,Relative Weights,"$7,186.59 ",IP,"7,186.59","7,186.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1401,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$2,639.05 ",IP,"2,639.05","2,639.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1402,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,167.20 ",IP,"3,167.20","3,167.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1403,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,958.92 ",IP,"3,958.92","3,958.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1404,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$5,969.47 ",IP,"5,969.47","5,969.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1411,ASTHMA,,Relative Weights,"$2,018.80 ",IP,"2,018.80","2,018.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1412,ASTHMA,,Relative Weights,"$2,763.78 ",IP,"2,763.78","2,763.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1413,ASTHMA,,Relative Weights,"$4,049.98 ",IP,"4,049.98","4,049.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1414,ASTHMA,,Relative Weights,"$6,508.28 ",IP,"6,508.28","6,508.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1421,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,358.26 ",IP,"3,358.26","3,358.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1422,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,679.89 ",IP,"3,679.89","3,679.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1423,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$4,888.08 ",IP,"4,888.08","4,888.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1424,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$7,901.68 ",IP,"7,901.68","7,901.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1431,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$2,504.69 ",IP,"2,504.69","2,504.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1432,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,509.11 ",IP,"3,509.11","3,509.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1433,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$5,145.11 ",IP,"5,145.11","5,145.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1434,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$8,358.70 ",IP,"8,358.70","8,358.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1441,"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",,Relative Weights,"$2,636.99 ",IP,"2,636.99","2,636.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1442,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,405.68 ",IP,"3,405.68","3,405.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1443,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$4,454.42 ",IP,"4,454.42","4,454.42",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1444,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$7,998.24 ",IP,"7,998.24","7,998.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1451,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,478.23 ",IP,"2,478.23","2,478.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1452,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,974.43 ",IP,"2,974.43","2,974.43",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1453,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$3,820.09 ",IP,"3,820.09","3,820.09",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1454,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$6,746.07 ",IP,"6,746.07","6,746.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1601,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$19,007.33 ",IP,"19,007.33","19,007.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1602,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$21,418.55 ",IP,"21,418.55","21,418.55",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1603,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$29,897.52 ",IP,"29,897.52","29,897.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1604,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$58,616.75 ",IP,"58,616.75","58,616.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1611,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$21,623.70 ",IP,"21,623.70","21,623.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1612,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$25,324.21 ",IP,"25,324.21","25,324.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1613,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$37,168.99 ",IP,"37,168.99","37,168.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1614,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$84,952.59 ",IP,"84,952.59","84,952.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1621,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$21,734.00 ",IP,"21,734.00","21,734.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1622,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$25,647.21 ",IP,"25,647.21","25,647.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1623,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$32,557.19 ",IP,"32,557.19","32,557.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1624,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$51,493.39 ",IP,"51,493.39","51,493.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1631,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$18,870.57 ",IP,"18,870.57","18,870.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1632,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$20,678.38 ",IP,"20,678.38","20,678.38",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1633,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$25,441.73 ",IP,"25,441.73","25,441.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1634,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$42,290.40 ",IP,"42,290.40","42,290.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1651,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$17,424.93 ",IP,"17,424.93","17,424.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1652,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$20,592.13 ",IP,"20,592.13","20,592.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1653,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$24,876.46 ",IP,"24,876.46","24,876.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1654,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$37,414.00 ",IP,"37,414.00","37,414.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1661,CORONARY BYPASS W/O AMI OR COMPLEX PDX,,Relative Weights,"$16,087.19 ",IP,"16,087.19","16,087.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1662,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$17,173.40 ",IP,"17,173.40","17,173.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1663,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$20,743.67 ",IP,"20,743.67","20,743.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1664,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$33,503.88 ",IP,"33,503.88","33,503.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1671,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$15,753.88 ",IP,"15,753.88","15,753.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1672,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$16,654.52 ",IP,"16,654.52","16,654.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1673,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$20,943.66 ",IP,"20,943.66","20,943.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1674,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$39,564.41 ",IP,"39,564.41","39,564.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1691,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$9,314.67 ",IP,"9,314.67","9,314.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1692,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$12,244.08 ",IP,"12,244.08","12,244.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1693,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$19,456.45 ",IP,"19,456.45","19,456.45",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1694,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$33,906.95 ",IP,"33,906.95","33,906.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1701,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,265.14 ",IP,"10,265.14","10,265.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1702,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,949.99 ",IP,"10,949.99","10,949.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1703,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$13,975.61 ",IP,"13,975.61","13,975.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1704,"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",,Relative Weights,"$19,895.26 ",IP,"19,895.26","19,895.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1711,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$8,272.45 ",IP,"8,272.45","8,272.45",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1712,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$9,180.66 ",IP,"9,180.66","9,180.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1713,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,971.29 ",IP,"10,971.29","10,971.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1714,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$17,965.80 ",IP,"17,965.80","17,965.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1741,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$9,597.47 ",IP,"9,597.47","9,597.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1742,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$10,364.10 ",IP,"10,364.10","10,364.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1743,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$12,874.29 ",IP,"12,874.29","12,874.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1744,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$19,364.01 ",IP,"19,364.01","19,364.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1751,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$11,256.84 ",IP,"11,256.84","11,256.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1752,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$12,009.39 ",IP,"12,009.39","12,009.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1753,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$14,253.95 ",IP,"14,253.95","14,253.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1754,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$25,147.58 ",IP,"25,147.58","25,147.58",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1761,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$9,268.97 ",IP,"9,268.97","9,268.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1762,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$10,537.63 ",IP,"10,537.63","10,537.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1763,CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$15,961.08 ",IP,"15,961.08","15,961.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1764,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$25,961.29 ",IP,"25,961.29","25,961.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1771,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$6,530.96 ",IP,"6,530.96","6,530.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1772,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$9,029.80 ",IP,"9,029.80","9,029.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1773,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$11,280.21 ",IP,"11,280.21","11,280.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1774,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$17,033.20 ",IP,"17,033.20","17,033.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1801,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$6,351.58 ",IP,"6,351.58","6,351.58",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1802,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$7,715.78 ",IP,"7,715.78","7,715.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1803,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$10,872.33 ",IP,"10,872.33","10,872.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1804,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$20,062.95 ",IP,"20,062.95","20,062.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1811,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$9,268.28 ",IP,"9,268.28","9,268.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1812,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$11,438.97 ",IP,"11,438.97","11,438.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1813,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$16,303.68 ",IP,"16,303.68","16,303.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1814,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$27,105.22 ",IP,"27,105.22","27,105.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1821,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$9,585.79 ",IP,"9,585.79","9,585.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1822,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$11,451.68 ",IP,"11,451.68","11,451.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1823,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$12,966.73 ",IP,"12,966.73","12,966.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1824,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$25,526.94 ",IP,"25,526.94","25,526.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1901,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$3,454.82 ",IP,"3,454.82","3,454.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1902,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$4,023.17 ",IP,"4,023.17","4,023.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1903,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$5,278.78 ",IP,"5,278.78","5,278.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1904,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$8,568.66 ",IP,"8,568.66","8,568.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1911,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$4,795.99 ",IP,"4,795.99","4,795.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1912,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$5,349.23 ",IP,"5,349.23","5,349.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1913,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$6,652.26 ",IP,"6,652.26","6,652.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1914,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$10,568.22 ",IP,"10,568.22","10,568.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1921,CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,,Relative Weights,"$5,126.56 ",IP,"5,126.56","5,126.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1922,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$5,995.59 ",IP,"5,995.59","5,995.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1923,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$8,192.04 ",IP,"8,192.04","8,192.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1924,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$14,030.25 ",IP,"14,030.25","14,030.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1931,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$4,156.16 ",IP,"4,156.16","4,156.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1932,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$5,201.81 ",IP,"5,201.81","5,201.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1933,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$7,472.15 ",IP,"7,472.15","7,472.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1934,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$12,655.75 ",IP,"12,655.75","12,655.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1941,HEART FAILURE,,Relative Weights,"$2,590.60 ",IP,"2,590.60","2,590.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1942,HEART FAILURE,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1943,HEART FAILURE,,Relative Weights,"$4,368.86 ",IP,"4,368.86","4,368.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1944,HEART FAILURE,,Relative Weights,"$7,070.79 ",IP,"7,070.79","7,070.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1961,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,365.52 ",IP,"2,365.52","2,365.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1962,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,596.44 ",IP,"2,596.44","2,596.44",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1963,CARDIAC ARREST & SHOCK,,Relative Weights,"$4,010.12 ",IP,"4,010.12","4,010.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1964,CARDIAC ARREST & SHOCK,,Relative Weights,"$8,325.03 ",IP,"8,325.03","8,325.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1971,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$2,758.63 ",IP,"2,758.63","2,758.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1972,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$3,488.49 ",IP,"3,488.49","3,488.49",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1973,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$4,794.61 ",IP,"4,794.61","4,794.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1974,PERIPHERAL & OTHER VASCULAR DISORDERS,,Relative Weights,"$9,053.51 ",IP,"9,053.51","9,053.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1981,ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,680.28 ",IP,"2,680.28","2,680.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1982,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,985.77 ",IP,"2,985.77","2,985.77",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1983,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$3,628.00 ",IP,"3,628.00","3,628.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1984,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$6,763.25 ",IP,"6,763.25","6,763.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1991,HYPERTENSION,,Relative Weights,"$2,662.41 ",IP,"2,662.41","2,662.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1992,HYPERTENSION,,Relative Weights,"$2,956.56 ",IP,"2,956.56","2,956.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1993,HYPERTENSION,,Relative Weights,"$3,736.93 ",IP,"3,736.93","3,736.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,1994,HYPERTENSION,,Relative Weights,"$6,634.39 ",IP,"6,634.39","6,634.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2001,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$2,919.45 ",IP,"2,919.45","2,919.45",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2002,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$3,565.12 ",IP,"3,565.12","3,565.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2003,CARDIAC STRUCTURAL & VALVULAR DISORDERS,,Relative Weights,"$4,853.03 ",IP,"4,853.03","4,853.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2004,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$10,524.92 ",IP,"10,524.92","10,524.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2011,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,322.91 ",IP,"2,322.91","2,322.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2012,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,865.50 ",IP,"2,865.50","2,865.50",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2013,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$3,988.81 ",IP,"3,988.81","3,988.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2014,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$7,490.70 ",IP,"7,490.70","7,490.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2031,CHEST PAIN,,Relative Weights,"$2,896.08 ",IP,"2,896.08","2,896.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2032,CHEST PAIN,,Relative Weights,"$3,156.55 ",IP,"3,156.55","3,156.55",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2033,CHEST PAIN,,Relative Weights,"$3,647.25 ",IP,"3,647.25","3,647.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2034,CHEST PAIN,,Relative Weights,"$5,656.08 ",IP,"5,656.08","5,656.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2041,SYNCOPE and COLLAPSE,,Relative Weights,"$3,210.15 ",IP,"3,210.15","3,210.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2042,SYNCOPE and COLLAPSE,,Relative Weights,"$3,469.25 ",IP,"3,469.25","3,469.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2043,SYNCOPE and COLLAPSE,,Relative Weights,"$3,913.56 ",IP,"3,913.56","3,913.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2044,SYNCOPE and COLLAPSE,,Relative Weights,"$6,621.67 ",IP,"6,621.67","6,621.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2051,CARDIOMYOPATHY,,Relative Weights,"$3,094.70 ",IP,"3,094.70","3,094.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2052,CARDIOMYOPATHY,,Relative Weights,"$3,108.78 ",IP,"3,108.78","3,108.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2053,CARDIOMYOPATHY,,Relative Weights,"$4,834.47 ",IP,"4,834.47","4,834.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2054,CARDIOMYOPATHY,,Relative Weights,"$12,099.76 ",IP,"12,099.76","12,099.76",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2061,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$3,915.62 ",IP,"3,915.62","3,915.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2062,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$4,064.41 ",IP,"4,064.41","4,064.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2063,"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",,Relative Weights,"$5,616.22 ",IP,"5,616.22","5,616.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2064,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$11,629.68 ",IP,"11,629.68","11,629.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2071,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$2,947.97 ",IP,"2,947.97","2,947.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2072,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$3,511.17 ",IP,"3,511.17","3,511.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2073,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$4,590.50 ",IP,"4,590.50","4,590.50",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2074,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$8,837.72 ",IP,"8,837.72","8,837.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2201,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$7,004.47 ",IP,"7,004.47","7,004.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2202,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$10,124.94 ",IP,"10,124.94","10,124.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2203,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$15,446.33 ",IP,"15,446.33","15,446.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2204,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$29,728.80 ",IP,"29,728.80","29,728.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2221,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$3,629.38 ",IP,"3,629.38","3,629.38",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2222,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$5,962.94 ",IP,"5,962.94","5,962.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2223,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$9,116.74 ",IP,"9,116.74","9,116.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2224,"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",,Relative Weights,"$19,946.46 ",IP,"19,946.46","19,946.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2231,OTHER SMALL & LARGE BOWEL PROCEDURES,,Relative Weights,"$5,180.51 ",IP,"5,180.51","5,180.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2232,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$7,107.90 ",IP,"7,107.90","7,107.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2233,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$10,759.27 ",IP,"10,759.27","10,759.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2234,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$20,449.53 ",IP,"20,449.53","20,449.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2241,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$6,143.69 ",IP,"6,143.69","6,143.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2242,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$7,746.36 ",IP,"7,746.36","7,746.36",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2243,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$11,242.41 ",IP,"11,242.41","11,242.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2244,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$20,422.04 ",IP,"20,422.04","20,422.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2261,ANAL PROCEDURES,,Relative Weights,"$4,263.71 ",IP,"4,263.71","4,263.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2262,ANAL PROCEDURES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2263,ANAL PROCEDURES,,Relative Weights,"$7,950.47 ",IP,"7,950.47","7,950.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2264,ANAL PROCEDURES,,Relative Weights,"$17,017.73 ",IP,"17,017.73","17,017.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2271,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$5,689.07 ",IP,"5,689.07","5,689.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2272,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$6,795.89 ",IP,"6,795.89","6,795.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2273,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$10,114.97 ",IP,"10,114.97","10,114.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2274,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$20,038.21 ",IP,"20,038.21","20,038.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2281,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$4,335.53 ",IP,"4,335.53","4,335.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2282,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$5,502.48 ",IP,"5,502.48","5,502.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2283,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$7,788.28 ",IP,"7,788.28","7,788.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2284,"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",,Relative Weights,"$16,501.95 ",IP,"16,501.95","16,501.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2291,OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,,Relative Weights,"$5,564.34 ",IP,"5,564.34","5,564.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2292,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$7,117.87 ",IP,"7,117.87","7,117.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2293,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$10,259.30 ",IP,"10,259.30","10,259.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2294,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$20,018.28 ",IP,"20,018.28","20,018.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2301,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$6,770.12 ",IP,"6,770.12","6,770.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2302,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$8,787.20 ",IP,"8,787.20","8,787.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2303,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$13,506.56 ",IP,"13,506.56","13,506.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2304,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$27,168.10 ",IP,"27,168.10","27,168.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2311,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$6,900.01 ",IP,"6,900.01","6,900.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2312,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$8,451.83 ",IP,"8,451.83","8,451.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2313,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$12,656.43 ",IP,"12,656.43","12,656.43",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2314,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$23,212.62 ",IP,"23,212.62","23,212.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2321,GASTRIC FUNDOPLICATION,,Relative Weights,"$5,317.96 ",IP,"5,317.96","5,317.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2322,GASTRIC FUNDOPLICATION,,Relative Weights,"$6,619.27 ",IP,"6,619.27","6,619.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2323,GASTRIC FUNDOPLICATION,,Relative Weights,"$9,668.60 ",IP,"9,668.60","9,668.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2324,GASTRIC FUNDOPLICATION,,Relative Weights,"$26,510.06 ",IP,"26,510.06","26,510.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2331,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,328.61 ",IP,"5,328.61","5,328.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2332,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,525.46 ",IP,"6,525.46","6,525.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2333,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,426.35 ",IP,"9,426.35","9,426.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2334,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$16,969.28 ",IP,"16,969.28","16,969.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2341,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2342,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,853.72 ",IP,"4,853.72","4,853.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2343,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,767.67 ",IP,"7,767.67","7,767.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2344,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$15,153.91 ",IP,"15,153.91","15,153.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2401,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,130.38 ",IP,"4,130.38","4,130.38",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2402,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,471.61 ",IP,"4,471.61","4,471.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2403,DIGESTIVE MALIGNANCY,,Relative Weights,"$5,940.95 ",IP,"5,940.95","5,940.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2404,DIGESTIVE MALIGNANCY,,Relative Weights,"$10,480.94 ",IP,"10,480.94","10,480.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2411,PEPTIC ULCER & GASTRITIS,,Relative Weights,"$3,142.46 ",IP,"3,142.46","3,142.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2412,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$3,833.49 ",IP,"3,833.49","3,833.49",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2413,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2414,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$11,497.38 ",IP,"11,497.38","11,497.38",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2421,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$2,834.23 ",IP,"2,834.23","2,834.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2422,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$3,630.75 ",IP,"3,630.75","3,630.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2423,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$5,095.29 ",IP,"5,095.29","5,095.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2424,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$11,235.54 ",IP,"11,235.54","11,235.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2431,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$2,619.12 ",IP,"2,619.12","2,619.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2432,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$3,394.34 ",IP,"3,394.34","3,394.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2433,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$4,672.28 ",IP,"4,672.28","4,672.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2434,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$10,028.72 ",IP,"10,028.72","10,028.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2441,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$2,541.46 ",IP,"2,541.46","2,541.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2442,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$3,268.57 ",IP,"3,268.57","3,268.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2443,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$4,670.91 ",IP,"4,670.91","4,670.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2444,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$10,075.80 ",IP,"10,075.80","10,075.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2451,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,109.82 ",IP,"3,109.82","3,109.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2452,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,884.35 ",IP,"3,884.35","3,884.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2453,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$5,370.53 ",IP,"5,370.53","5,370.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2454,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$12,127.25 ",IP,"12,127.25","12,127.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2461,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,009.82 ",IP,"3,009.82","3,009.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2462,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,644.84 ",IP,"3,644.84","3,644.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2463,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$5,068.14 ",IP,"5,068.14","5,068.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2464,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2471,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,323.60 ",IP,"2,323.60","2,323.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2472,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,999.17 ",IP,"2,999.17","2,999.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2473,INTESTINAL OBSTRUCTION,,Relative Weights,"$4,431.74 ",IP,"4,431.74","4,431.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2474,INTESTINAL OBSTRUCTION,,Relative Weights,"$9,108.15 ",IP,"9,108.15","9,108.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2481,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$2,573.42 ",IP,"2,573.42","2,573.42",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2482,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$3,590.89 ",IP,"3,590.89","3,590.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2483,MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,,Relative Weights,"$4,839.63 ",IP,"4,839.63","4,839.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2484,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$10,133.19 ",IP,"10,133.19","10,133.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2491,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,187.52 ",IP,"2,187.52","2,187.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2492,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,797.80 ",IP,"2,797.80","2,797.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2493,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$3,754.80 ",IP,"3,754.80","3,754.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2494,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$8,298.22 ",IP,"8,298.22","8,298.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2511,ABDOMINAL PAIN,,Relative Weights,"$2,520.84 ",IP,"2,520.84","2,520.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2512,ABDOMINAL PAIN,,Relative Weights,"$3,175.79 ",IP,"3,175.79","3,175.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2513,ABDOMINAL PAIN,,Relative Weights,"$4,112.86 ",IP,"4,112.86","4,112.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2514,ABDOMINAL PAIN,,Relative Weights,"$7,334.01 ",IP,"7,334.01","7,334.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2521,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$2,913.26 ",IP,"2,913.26","2,913.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2522,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$3,639.34 ",IP,"3,639.34","3,639.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2523,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$5,172.60 ",IP,"5,172.60","5,172.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2524,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$11,168.53 ",IP,"11,168.53","11,168.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2531,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$2,890.24 ",IP,"2,890.24","2,890.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2532,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$3,602.23 ",IP,"3,602.23","3,602.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2533,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$5,054.39 ",IP,"5,054.39","5,054.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2534,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$9,586.48 ",IP,"9,586.48","9,586.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2541,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$2,614.99 ",IP,"2,614.99","2,614.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2542,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$3,386.43 ",IP,"3,386.43","3,386.43",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2543,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$4,771.93 ",IP,"4,771.93","4,771.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2544,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$9,778.91 ",IP,"9,778.91","9,778.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2601,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$9,438.72 ",IP,"9,438.72","9,438.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2602,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$11,500.13 ",IP,"11,500.13","11,500.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2603,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$16,312.61 ",IP,"16,312.61","16,312.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2604,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$34,324.11 ",IP,"34,324.11","34,324.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2611,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$6,801.05 ",IP,"6,801.05","6,801.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2612,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$10,119.10 ",IP,"10,119.10","10,119.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2613,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$14,491.05 ",IP,"14,491.05","14,491.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2614,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$28,576.97 ",IP,"28,576.97","28,576.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2631,CHOLECYSTECTOMY,,Relative Weights,"$5,153.36 ",IP,"5,153.36","5,153.36",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2632,CHOLECYSTECTOMY,,Relative Weights,"$6,574.60 ",IP,"6,574.60","6,574.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2633,CHOLECYSTECTOMY,,Relative Weights,"$8,823.28 ",IP,"8,823.28","8,823.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2634,CHOLECYSTECTOMY,,Relative Weights,"$16,983.37 ",IP,"16,983.37","16,983.37",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2641,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$6,826.47 ",IP,"6,826.47","6,826.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2642,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$7,584.86 ",IP,"7,584.86","7,584.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2643,"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",,Relative Weights,"$11,612.15 ",IP,"11,612.15","11,612.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2644,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$29,218.86 ",IP,"29,218.86","29,218.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2791,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$2,567.92 ",IP,"2,567.92","2,567.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2792,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$3,323.89 ",IP,"3,323.89","3,323.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2793,HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$4,704.93 ",IP,"4,704.93","4,704.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2794,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$11,290.86 ",IP,"11,290.86","11,290.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2801,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$2,499.54 ",IP,"2,499.54","2,499.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2802,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$3,093.32 ",IP,"3,093.32","3,093.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2803,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$4,638.26 ",IP,"4,638.26","4,638.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2804,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$10,324.24 ",IP,"10,324.24","10,324.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2811,MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,,Relative Weights,"$3,619.41 ",IP,"3,619.41","3,619.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2812,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2813,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$5,844.73 ",IP,"5,844.73","5,844.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2814,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$9,186.50 ",IP,"9,186.50","9,186.50",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2821,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$2,462.42 ",IP,"2,462.42","2,462.42",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2822,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2823,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$4,746.16 ",IP,"4,746.16","4,746.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2824,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$12,503.18 ",IP,"12,503.18","12,503.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2831,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$2,720.83 ",IP,"2,720.83","2,720.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2832,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$3,349.67 ",IP,"3,349.67","3,349.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2833,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$4,885.67 ",IP,"4,885.67","4,885.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2834,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$10,248.65 ",IP,"10,248.65","10,248.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2841,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$3,351.73 ",IP,"3,351.73","3,351.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2842,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$4,147.57 ",IP,"4,147.57","4,147.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2843,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$5,552.31 ",IP,"5,552.31","5,552.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,2844,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$10,788.48 ",IP,"10,788.48","10,788.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3011,HIP JOINT REPLACEMENT,,Relative Weights,"$7,771.10 ",IP,"7,771.10","7,771.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3012,HIP JOINT REPLACEMENT,,Relative Weights,"$8,122.29 ",IP,"8,122.29","8,122.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3013,HIP JOINT REPLACEMENT,,Relative Weights,"$10,480.59 ",IP,"10,480.59","10,480.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3014,HIP JOINT REPLACEMENT,,Relative Weights,"$16,617.41 ",IP,"16,617.41","16,617.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3021,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,208.24 ",IP,"7,208.24","7,208.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3022,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,702.03 ",IP,"7,702.03","7,702.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3023,KNEE JOINT REPLACEMENT,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3024,KNEE JOINT REPLACEMENT,,Relative Weights,"$17,075.12 ",IP,"17,075.12","17,075.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3031,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$22,622.27 ",IP,"22,622.27","22,622.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3032,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$26,401.82 ",IP,"26,401.82","26,401.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3033,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$36,462.15 ",IP,"36,462.15","36,462.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3034,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$46,680.22 ",IP,"46,680.22","46,680.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3041,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$13,662.91 ",IP,"13,662.91","13,662.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3042,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$15,568.66 ",IP,"15,568.66","15,568.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3043,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$23,409.86 ",IP,"23,409.86","23,409.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3044,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$37,522.24 ",IP,"37,522.24","37,522.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3051,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$4,866.09 ",IP,"4,866.09","4,866.09",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3052,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$6,637.82 ",IP,"6,637.82","6,637.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3053,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$10,080.61 ",IP,"10,080.61","10,080.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3054,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$19,786.33 ",IP,"19,786.33","19,786.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3081,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$6,633.70 ",IP,"6,633.70","6,633.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3082,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$7,529.88 ",IP,"7,529.88","7,529.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3083,HIP & FEMUR FRACTURE REPAIR,,Relative Weights,"$9,249.72 ",IP,"9,249.72","9,249.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3084,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$14,744.30 ",IP,"14,744.30","14,744.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3091,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$7,238.83 ",IP,"7,238.83","7,238.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3092,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$9,130.83 ",IP,"9,130.83","9,130.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3093,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$12,063.33 ",IP,"12,063.33","12,063.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3094,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$21,019.95 ",IP,"21,019.95","21,019.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3101,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$5,634.78 ",IP,"5,634.78","5,634.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3102,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$6,775.27 ",IP,"6,775.27","6,775.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3103,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$9,328.07 ",IP,"9,328.07","9,328.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3104,INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,,Relative Weights,"$18,301.18 ",IP,"18,301.18","18,301.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3121,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$6,515.49 ",IP,"6,515.49","6,515.49",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3122,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,587.21 ",IP,"8,587.21","8,587.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3123,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$12,636.50 ",IP,"12,636.50","12,636.50",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3124,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$31,602.60 ",IP,"31,602.60","31,602.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3131,KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$5,906.59 ",IP,"5,906.59","5,906.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3132,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$7,791.03 ",IP,"7,791.03","7,791.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3133,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$10,674.40 ",IP,"10,674.40","10,674.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3134,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$18,704.94 ",IP,"18,704.94","18,704.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3141,FOOT & TOE PROCEDURES,,Relative Weights,"$5,184.29 ",IP,"5,184.29","5,184.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3142,FOOT and TOE PROCEDURES,,Relative Weights,"$5,760.89 ",IP,"5,760.89","5,760.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3143,FOOT and TOE PROCEDURES,,Relative Weights,"$7,587.61 ",IP,"7,587.61","7,587.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3144,FOOT and TOE PROCEDURES,,Relative Weights,"$15,541.86 ",IP,"15,541.86","15,541.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3151,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$4,407.35 ",IP,"4,407.35","4,407.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3152,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$7,204.46 ",IP,"7,204.46","7,204.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3153,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$9,814.99 ",IP,"9,814.99","9,814.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3154,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$17,630.42 ",IP,"17,630.42","17,630.42",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3161,HAND and WRIST PROCEDURES,,Relative Weights,"$4,228.66 ",IP,"4,228.66","4,228.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3162,HAND and WRIST PROCEDURES,,Relative Weights,"$5,513.82 ",IP,"5,513.82","5,513.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3163,HAND and WRIST PROCEDURES,,Relative Weights,"$8,327.78 ",IP,"8,327.78","8,327.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3164,HAND and WRIST PROCEDURES,,Relative Weights,"$17,742.44 ",IP,"17,742.44","17,742.44",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3171,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$4,914.20 ",IP,"4,914.20","4,914.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3172,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$6,410.69 ",IP,"6,410.69","6,410.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3173,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$9,611.56 ",IP,"9,611.56","9,611.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3174,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$20,290.08 ",IP,"20,290.08","20,290.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3201,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$5,415.55 ",IP,"5,415.55","5,415.55",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3202,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$6,995.19 ",IP,"6,995.19","6,995.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3203,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$10,390.22 ",IP,"10,390.22","10,390.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3204,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$19,965.01 ",IP,"19,965.01","19,965.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3211,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$8,441.17 ",IP,"8,441.17","8,441.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3212,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$10,023.57 ",IP,"10,023.57","10,023.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3213,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$14,027.50 ",IP,"14,027.50","14,027.50",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3214,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$25,569.90 ",IP,"25,569.90","25,569.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3221,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,466.60 ",IP,"8,466.60","8,466.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3222,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3223,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$11,526.59 ",IP,"11,526.59","11,526.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3224,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$17,494.69 ",IP,"17,494.69","17,494.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3401,FRACTURE OF FEMUR,,Relative Weights,"$2,284.43 ",IP,"2,284.43","2,284.43",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3402,FRACTURE OF FEMUR,,Relative Weights,"$2,649.70 ",IP,"2,649.70","2,649.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3403,FRACTURE OF FEMUR,,Relative Weights,"$3,664.08 ",IP,"3,664.08","3,664.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3404,FRACTURE OF FEMUR,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3411,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,584.41 ",IP,"2,584.41","2,584.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3412,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,958.62 ",IP,"2,958.62","2,958.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3413,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$3,751.71 ",IP,"3,751.71","3,751.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3414,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$8,259.05 ",IP,"8,259.05","8,259.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3421,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$2,677.53 ",IP,"2,677.53","2,677.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3422,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$3,262.04 ",IP,"3,262.04","3,262.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3423,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$4,236.57 ",IP,"4,236.57","4,236.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3424,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$8,410.59 ",IP,"8,410.59","8,410.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3431,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,528.30 ",IP,"4,528.30","4,528.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3432,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,916.60 ",IP,"4,916.60","4,916.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3433,MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,,Relative Weights,"$6,907.57 ",IP,"6,907.57","6,907.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3434,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$11,710.09 ",IP,"11,710.09","11,710.09",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3441,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$3,603.61 ",IP,"3,603.61","3,603.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3442,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$4,272.99 ",IP,"4,272.99","4,272.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3443,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$5,859.85 ",IP,"5,859.85","5,859.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3444,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$10,885.73 ",IP,"10,885.73","10,885.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3461,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$3,601.54 ",IP,"3,601.54","3,601.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3462,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$4,539.99 ",IP,"4,539.99","4,539.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3463,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$6,445.74 ",IP,"6,445.74","6,445.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3464,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$15,116.11 ",IP,"15,116.11","15,116.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3471,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$3,279.91 ",IP,"3,279.91","3,279.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3472,"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",,Relative Weights,"$3,772.33 ",IP,"3,772.33","3,772.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3473,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$4,894.95 ",IP,"4,894.95","4,894.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3474,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3491,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$2,603.31 ",IP,"2,603.31","2,603.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3492,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$3,535.91 ",IP,"3,535.91","3,535.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3493,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$5,006.97 ",IP,"5,006.97","5,006.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3494,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$9,666.89 ",IP,"9,666.89","9,666.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3511,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3512,OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$3,066.17 ",IP,"3,066.17","3,066.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3513,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$4,449.61 ",IP,"4,449.61","4,449.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3514,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,785.14 ",IP,"8,785.14","8,785.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3611,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3612,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$6,759.47 ",IP,"6,759.47","6,759.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3613,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$10,411.18 ",IP,"10,411.18","10,411.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3614,SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$23,051.12 ",IP,"23,051.12","23,051.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3621,MASTECTOMY PROCEDURES,,Relative Weights,"$5,733.06 ",IP,"5,733.06","5,733.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3622,MASTECTOMY PROCEDURES,,Relative Weights,"$6,783.86 ",IP,"6,783.86","6,783.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3623,MASTECTOMY PROCEDURES,,Relative Weights,"$8,730.85 ",IP,"8,730.85","8,730.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3624,MASTECTOMY PROCEDURES,,Relative Weights,"$15,662.13 ",IP,"15,662.13","15,662.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3631,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$5,772.23 ",IP,"5,772.23","5,772.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3632,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$7,919.20 ",IP,"7,919.20","7,919.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3633,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$10,641.07 ",IP,"10,641.07","10,641.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3634,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$13,007.96 ",IP,"13,007.96","13,007.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3641,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$3,659.27 ",IP,"3,659.27","3,659.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3642,"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",,Relative Weights,"$5,232.39 ",IP,"5,232.39","5,232.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3643,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$8,152.18 ",IP,"8,152.18","8,152.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3644,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$16,685.79 ",IP,"16,685.79","16,685.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3801,SKIN ULCERS,,Relative Weights,"$2,950.72 ",IP,"2,950.72","2,950.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3802,SKIN ULCERS,,Relative Weights,"$3,415.64 ",IP,"3,415.64","3,415.64",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3803,SKIN ULCERS,,Relative Weights,"$4,667.13 ",IP,"4,667.13","4,667.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3804,SKIN ULCERS,,Relative Weights,"$9,197.15 ",IP,"9,197.15","9,197.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3811,MAJOR SKIN DISORDERS,,Relative Weights,"$2,135.64 ",IP,"2,135.64","2,135.64",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3812,MAJOR SKIN DISORDERS,,Relative Weights,"$3,426.98 ",IP,"3,426.98","3,426.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3813,MAJOR SKIN DISORDERS,,Relative Weights,"$6,058.47 ",IP,"6,058.47","6,058.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3814,MAJOR SKIN DISORDERS,,Relative Weights,"$15,997.51 ",IP,"15,997.51","15,997.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3821,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,708.41 ",IP,"3,708.41","3,708.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3822,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3823,MALIGNANT BREAST DISORDERS,,Relative Weights,"$5,221.05 ",IP,"5,221.05","5,221.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3824,MALIGNANT BREAST DISORDERS,,Relative Weights,"$8,582.75 ",IP,"8,582.75","8,582.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3831,CELLULITIS & OTHER SKIN INFECTIONS,,Relative Weights,"$2,128.08 ",IP,"2,128.08","2,128.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3832,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$2,886.11 ",IP,"2,886.11","2,886.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3833,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$4,151.00 ",IP,"4,151.00","4,151.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3834,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$8,552.16 ",IP,"8,552.16","8,552.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3841,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$2,690.94 ",IP,"2,690.94","2,690.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3842,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$3,464.09 ",IP,"3,464.09","3,464.09",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3843,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$4,737.92 ",IP,"4,737.92","4,737.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3844,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$9,439.41 ",IP,"9,439.41","9,439.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3851,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,189.24 ",IP,"2,189.24","2,189.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3852,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,880.96 ",IP,"2,880.96","2,880.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3853,"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",,Relative Weights,"$4,186.05 ",IP,"4,186.05","4,186.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,3854,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$8,871.05 ",IP,"8,871.05","8,871.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4011,ADRENAL PROCEDURES,,Relative Weights,"$6,855.68 ",IP,"6,855.68","6,855.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4012,ADRENAL PROCEDURES,,Relative Weights,"$10,778.52 ",IP,"10,778.52","10,778.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4013,ADRENAL PROCEDURES,,Relative Weights,"$13,300.04 ",IP,"13,300.04","13,300.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4014,ADRENAL PROCEDURES,,Relative Weights,"$24,027.70 ",IP,"24,027.70","24,027.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4031,PROCEDURES FOR OBESITY,,Relative Weights,"$5,110.06 ",IP,"5,110.06","5,110.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4032,PROCEDURES FOR OBESITY,,Relative Weights,"$6,108.30 ",IP,"6,108.30","6,108.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4033,PROCEDURES FOR OBESITY,,Relative Weights,"$9,074.13 ",IP,"9,074.13","9,074.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4034,PROCEDURES FOR OBESITY,,Relative Weights,"$26,392.19 ",IP,"26,392.19","26,392.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4041,"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",,Relative Weights,"$4,728.64 ",IP,"4,728.64","4,728.64",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4042,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4043,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$10,989.85 ",IP,"10,989.85","10,989.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4044,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$24,206.39 ",IP,"24,206.39","24,206.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4051,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$7,505.82 ",IP,"7,505.82","7,505.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4052,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$8,475.19 ",IP,"8,475.19","8,475.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4053,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$12,612.79 ",IP,"12,612.79","12,612.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4054,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$26,164.03 ",IP,"26,164.03","26,164.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4201,DIABETES,,Relative Weights,"$2,259.68 ",IP,"2,259.68","2,259.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4202,DIABETES,,Relative Weights,"$2,723.24 ",IP,"2,723.24","2,723.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4203,DIABETES,,Relative Weights,"$3,776.79 ",IP,"3,776.79","3,776.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4204,DIABETES,,Relative Weights,"$8,028.82 ",IP,"8,028.82","8,028.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4211,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$2,343.53 ",IP,"2,343.53","2,343.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4212,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$3,329.74 ",IP,"3,329.74","3,329.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4213,"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",,Relative Weights,"$5,181.88 ",IP,"5,181.88","5,181.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4214,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$10,295.72 ",IP,"10,295.72","10,295.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4221,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$1,870.01 ",IP,"1,870.01","1,870.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4222,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$2,609.84 ",IP,"2,609.84","2,609.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4223,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$3,459.28 ",IP,"3,459.28","3,459.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4224,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4231,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,529.29 ",IP,"5,529.29","5,529.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4232,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,948.85 ",IP,"5,948.85","5,948.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4233,INBORN ERRORS OF METABOLISM,,Relative Weights,"$8,447.01 ",IP,"8,447.01","8,447.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4234,INBORN ERRORS OF METABOLISM,,Relative Weights,"$27,194.91 ",IP,"27,194.91","27,194.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4241,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$2,869.62 ",IP,"2,869.62","2,869.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4242,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$3,662.02 ",IP,"3,662.02","3,662.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4243,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4244,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$10,807.73 ",IP,"10,807.73","10,807.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4251,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,221.89 ",IP,"2,221.89","2,221.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4252,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,908.79 ",IP,"2,908.79","2,908.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4253,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$3,943.11 ",IP,"3,943.11","3,943.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4254,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$7,662.17 ",IP,"7,662.17","7,662.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4261,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,409.16 ",IP,"2,409.16","2,409.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4262,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,941.78 ",IP,"2,941.78","2,941.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4263,NON-HYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$4,191.21 ",IP,"4,191.21","4,191.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4264,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$8,224.69 ",IP,"8,224.69","8,224.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4271,THYROID DISORDERS,,Relative Weights,"$2,411.91 ",IP,"2,411.91","2,411.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4272,THYROID DISORDERS,,Relative Weights,"$3,208.44 ",IP,"3,208.44","3,208.44",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4273,THYROID DISORDERS,,Relative Weights,"$4,621.77 ",IP,"4,621.77","4,621.77",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4274,THYROID DISORDERS,,Relative Weights,"$9,834.92 ",IP,"9,834.92","9,834.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4401,KIDNEY TRANSPLANT,,Relative Weights,"$26,376.39 ",IP,"26,376.39","26,376.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4402,KIDNEY TRANSPLANT,,Relative Weights,"$28,441.58 ",IP,"28,441.58","28,441.58",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4403,KIDNEY TRANSPLANT,,Relative Weights,"$31,863.75 ",IP,"31,863.75","31,863.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4404,KIDNEY TRANSPLANT,,Relative Weights,"$48,433.40 ",IP,"48,433.40","48,433.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4411,MAJOR BLADDER PROCEDURES,,Relative Weights,"$7,124.74 ",IP,"7,124.74","7,124.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4412,MAJOR BLADDER PROCEDURES,,Relative Weights,"$11,337.94 ",IP,"11,337.94","11,337.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4413,MAJOR BLADDER PROCEDURES,,Relative Weights,"$14,853.23 ",IP,"14,853.23","14,853.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4414,MAJOR BLADDER PROCEDURES,,Relative Weights,"$32,299.47 ",IP,"32,299.47","32,299.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4421,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,007.22 ",IP,"7,007.22","7,007.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4422,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,784.16 ",IP,"7,784.16","7,784.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4423,KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$11,551.33 ",IP,"11,551.33","11,551.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4424,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$20,973.56 ",IP,"20,973.56","20,973.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4431,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$5,745.77 ",IP,"5,745.77","5,745.77",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4432,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$6,928.19 ",IP,"6,928.19","6,928.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4433,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$10,300.53 ",IP,"10,300.53","10,300.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4434,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$21,259.80 ",IP,"21,259.80","21,259.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4441,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$6,643.67 ",IP,"6,643.67","6,643.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4442,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$8,351.49 ",IP,"8,351.49","8,351.49",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4443,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$12,840.62 ",IP,"12,840.62","12,840.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4444,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$25,251.70 ",IP,"25,251.70","25,251.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4451,OTHER BLADDER PROCEDURES,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4452,OTHER BLADDER PROCEDURES,,Relative Weights,"$6,607.93 ",IP,"6,607.93","6,607.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4453,OTHER BLADDER PROCEDURES,,Relative Weights,"$8,634.63 ",IP,"8,634.63","8,634.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4454,OTHER BLADDER PROCEDURES,,Relative Weights,"$17,913.22 ",IP,"17,913.22","17,913.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4461,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$4,096.37 ",IP,"4,096.37","4,096.37",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4462,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$5,093.91 ",IP,"5,093.91","5,093.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4463,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$7,454.97 ",IP,"7,454.97","7,454.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4464,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$15,279.67 ",IP,"15,279.67","15,279.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4471,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$6,383.54 ",IP,"6,383.54","6,383.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4472,"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",,Relative Weights,"$7,988.27 ",IP,"7,988.27","7,988.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4473,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$11,578.48 ",IP,"11,578.48","11,578.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4474,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$26,335.15 ",IP,"26,335.15","26,335.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4611,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,213.89 ",IP,"4,213.89","4,213.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4612,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,354.09 ",IP,"4,354.09","4,354.09",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4613,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$5,833.40 ",IP,"5,833.40","5,833.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4614,KIDNEY & URINARY TRACT MALIGNANCY,,Relative Weights,"$10,495.71 ",IP,"10,495.71","10,495.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4621,NEPHRITIS and NEPHROSIS,,Relative Weights,"$2,361.40 ",IP,"2,361.40","2,361.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4622,NEPHRITIS and NEPHROSIS,,Relative Weights,"$3,007.07 ",IP,"3,007.07","3,007.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4623,NEPHRITIS and NEPHROSIS,,Relative Weights,"$5,343.04 ",IP,"5,343.04","5,343.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4624,NEPHRITIS and NEPHROSIS,,Relative Weights,"$14,645.34 ",IP,"14,645.34","14,645.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4631,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,386.48 ",IP,"2,386.48","2,386.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4632,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,925.29 ",IP,"2,925.29","2,925.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4633,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$3,755.49 ",IP,"3,755.49","3,755.49",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4634,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$6,746.75 ",IP,"6,746.75","6,746.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4651,URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$2,676.16 ",IP,"2,676.16","2,676.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4652,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$3,212.22 ",IP,"3,212.22","3,212.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4653,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$4,385.36 ",IP,"4,385.36","4,385.36",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4654,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4661,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$2,602.62 ",IP,"2,602.62","2,602.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4662,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$3,336.61 ",IP,"3,336.61","3,336.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4663,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$4,821.07 ",IP,"4,821.07","4,821.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4664,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$8,281.73 ",IP,"8,281.73","8,281.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4681,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$2,645.58 ",IP,"2,645.58","2,645.58",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4682,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$3,341.08 ",IP,"3,341.08","3,341.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4683,"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",,Relative Weights,"$4,559.92 ",IP,"4,559.92","4,559.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4684,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$9,588.20 ",IP,"9,588.20","9,588.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4691,ACUTE KIDNEY INJURY,,Relative Weights,"$2,379.95 ",IP,"2,379.95","2,379.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4692,ACUTE KIDNEY INJURY,,Relative Weights,"$3,050.71 ",IP,"3,050.71","3,050.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4693,ACUTE KIDNEY INJURY,,Relative Weights,"$4,563.35 ",IP,"4,563.35","4,563.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4694,ACUTE KIDNEY INJURY,,Relative Weights,"$9,568.95 ",IP,"9,568.95","9,568.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4701,CHRONIC KIDNEY DISEASE,,Relative Weights,"$2,503.66 ",IP,"2,503.66","2,503.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4702,CHRONIC KIDNEY DISEASE,,Relative Weights,"$3,283.35 ",IP,"3,283.35","3,283.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4703,CHRONIC KIDNEY DISEASE,,Relative Weights,"$4,530.02 ",IP,"4,530.02","4,530.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4704,CHRONIC KIDNEY DISEASE,,Relative Weights,"$8,193.42 ",IP,"8,193.42","8,193.42",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4801,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,131.66 ",IP,"6,131.66","6,131.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4802,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,485.60 ",IP,"6,485.60","6,485.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4803,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$10,188.85 ",IP,"10,188.85","10,188.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4804,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$21,900.66 ",IP,"21,900.66","21,900.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4821,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,027.30 ",IP,"4,027.30","4,027.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4822,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,459.58 ",IP,"4,459.58","4,459.58",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4823,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$7,759.08 ",IP,"7,759.08","7,759.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4824,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$15,069.03 ",IP,"15,069.03","15,069.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4831,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$5,523.10 ",IP,"5,523.10","5,523.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4832,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$6,593.84 ",IP,"6,593.84","6,593.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4833,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$8,503.71 ",IP,"8,503.71","8,503.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4834,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$16,764.14 ",IP,"16,764.14","16,764.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4841,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,414.47 ",IP,"6,414.47","6,414.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4842,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4843,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,922.98 ",IP,"7,922.98","7,922.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,4844,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$22,148.41 ",IP,"22,148.41","22,148.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5001,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,471.31 ",IP,"3,471.31","3,471.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5002,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5003,"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",,Relative Weights,"$5,381.18 ",IP,"5,381.18","5,381.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5004,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$8,653.88 ",IP,"8,653.88","8,653.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5011,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,269.65 ",IP,"2,269.65","2,269.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5012,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,988.52 ",IP,"2,988.52","2,988.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5013,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$4,126.95 ",IP,"4,126.95","4,126.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5014,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$8,519.52 ",IP,"8,519.52","8,519.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5101,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$6,667.03 ",IP,"6,667.03","6,667.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5102,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$7,636.06 ",IP,"7,636.06","7,636.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5103,"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",,Relative Weights,"$12,159.55 ",IP,"12,159.55","12,159.55",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5104,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5111,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$6,477.69 ",IP,"6,477.69","6,477.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5112,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$7,830.89 ",IP,"7,830.89","7,830.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5113,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$10,746.90 ",IP,"10,746.90","10,746.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5114,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$23,120.88 ",IP,"23,120.88","23,120.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5121,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$6,341.62 ",IP,"6,341.62","6,341.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5122,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5123,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$9,937.66 ",IP,"9,937.66","9,937.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5124,UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,,Relative Weights,"$20,453.99 ",IP,"20,453.99","20,453.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5131,UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$4,384.67 ",IP,"4,384.67","4,384.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5132,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$5,107.31 ",IP,"5,107.31","5,107.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5133,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$8,107.86 ",IP,"8,107.86","8,107.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5134,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$16,632.53 ",IP,"16,632.53","16,632.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5141,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$3,945.51 ",IP,"3,945.51","3,945.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5142,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$5,893.19 ",IP,"5,893.19","5,893.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5143,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$10,581.96 ",IP,"10,581.96","10,581.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5144,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$22,849.41 ",IP,"22,849.41","22,849.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5171,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$3,258.61 ",IP,"3,258.61","3,258.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5172,DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,,Relative Weights,"$4,494.28 ",IP,"4,494.28","4,494.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5173,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$6,942.62 ",IP,"6,942.62","6,942.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5174,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$14,767.33 ",IP,"14,767.33","14,767.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5181,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$4,123.51 ",IP,"4,123.51","4,123.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5182,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$5,436.16 ",IP,"5,436.16","5,436.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5183,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$9,420.16 ",IP,"9,420.16","9,420.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5184,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$21,115.47 ",IP,"21,115.47","21,115.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5191,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,160.33 ",IP,"3,160.33","3,160.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5192,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,849.30 ",IP,"3,849.30","3,849.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5193,UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5194,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$15,622.96 ",IP,"15,622.96","15,622.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5301,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,382.31 ",IP,"3,382.31","3,382.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5302,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,815.97 ",IP,"3,815.97","3,815.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5303,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$5,327.23 ",IP,"5,327.23","5,327.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5304,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$9,039.08 ",IP,"9,039.08","9,039.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5311,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,096.46 ",IP,"2,096.46","2,096.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5312,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,868.93 ",IP,"2,868.93","2,868.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5313,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$4,503.56 ",IP,"4,503.56","4,503.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5314,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$9,958.97 ",IP,"9,958.97","9,958.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5321,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,302.29 ",IP,"2,302.29","2,302.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5322,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,696.78 ",IP,"2,696.78","2,696.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5323,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$4,143.44 ",IP,"4,143.44","4,143.44",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5324,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$9,044.24 ",IP,"9,044.24","9,044.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5401,CESAREAN DELIVERY,,Relative Weights,"$2,493.69 ",IP,"2,493.69","2,493.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5402,CESAREAN DELIVERY,,Relative Weights,"$2,909.48 ",IP,"2,909.48","2,909.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5403,CESAREAN DELIVERY,,Relative Weights,"$4,140.35 ",IP,"4,140.35","4,140.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5404,CESAREAN DELIVERY,,Relative Weights,"$8,525.02 ",IP,"8,525.02","8,525.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5411,VAGINAL DELIVERY W STERILIZATION &/OR D&C,,Relative Weights,"$2,683.03 ",IP,"2,683.03","2,683.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5412,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$2,694.03 ",IP,"2,694.03","2,694.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5413,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$3,800.85 ",IP,"3,800.85","3,800.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5414,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$9,356.59 ",IP,"9,356.59","9,356.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5421,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,,Relative Weights,"$1,729.81 ",IP,"1,729.81","1,729.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5422,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$1,962.10 ",IP,"1,962.10","1,962.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5423,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$2,979.24 ",IP,"2,979.24","2,979.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5424,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$11,346.53 ",IP,"11,346.53","11,346.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5441,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$1,946.30 ",IP,"1,946.30","1,946.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5442,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$2,595.06 ",IP,"2,595.06","2,595.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5443,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$3,856.51 ",IP,"3,856.51","3,856.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5444,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$14,310.30 ",IP,"14,310.30","14,310.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5451,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$2,785.09 ",IP,"2,785.09","2,785.09",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5452,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,114.63 ",IP,"3,114.63","3,114.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5453,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,214.96 ",IP,"3,214.96","3,214.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5454,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$4,812.48 ",IP,"4,812.48","4,812.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5461,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$2,385.45 ",IP,"2,385.45","2,385.45",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5462,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$4,587.41 ",IP,"4,587.41","4,587.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5463,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$5,857.79 ",IP,"5,857.79","5,857.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5464,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$11,895.30 ",IP,"11,895.30","11,895.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5601,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,539.10 ",IP,"1,539.10","1,539.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5602,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,659.37 ",IP,"1,659.37","1,659.37",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5603,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$2,337.34 ",IP,"2,337.34","2,337.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5604,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$4,292.23 ",IP,"4,292.23","4,292.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5611,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,236.71 ",IP,"1,236.71","1,236.71",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5612,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,778.26 ",IP,"1,778.26","1,778.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5613,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$2,747.29 ",IP,"2,747.29","2,747.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5614,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$5,898.34 ",IP,"5,898.34","5,898.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5631,PRETERM LABOR,,Relative Weights,"$1,387.56 ",IP,"1,387.56","1,387.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5632,PRETERM LABOR,,Relative Weights,"$1,719.85 ",IP,"1,719.85","1,719.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5633,PRETERM LABOR,,Relative Weights,"$2,634.92 ",IP,"2,634.92","2,634.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5634,PRETERM LABOR,,Relative Weights,"$4,637.23 ",IP,"4,637.23","4,637.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5641,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$1,463.85 ",IP,"1,463.85","1,463.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5642,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$1,520.55 ",IP,"1,520.55","1,520.55",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5643,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$2,435.62 ",IP,"2,435.62","2,435.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5644,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$3,935.55 ",IP,"3,935.55","3,935.55",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5651,FALSE LABOR,FALSE LABOR,Relative Weights,$992.39 ,IP,992.39,992.39,,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5652,FALSE LABOR,FALSE LABOR,Relative Weights,"$1,254.23 ",IP,"1,254.23","1,254.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5653,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5654,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5661,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,462.82 ",IP,"1,462.82","1,462.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5662,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,906.44 ",IP,"1,906.44","1,906.44",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5663,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$2,718.08 ",IP,"2,718.08","2,718.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5664,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$5,715.19 ",IP,"5,715.19","5,715.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5801,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$1,625.35 ",IP,"1,625.35","1,625.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5802,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$2,301.61 ",IP,"2,301.61","2,301.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5803,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$3,477.84 ",IP,"3,477.84","3,477.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5804,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5811,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,$559.42 ,IP,559.42,559.42,,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5812,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,$716.80 ,IP,716.8,716.8,,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5813,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,"$1,204.41 ",IP,"1,204.41","1,204.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5814,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,"$2,109.52 ",IP,"2,109.52","2,109.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5831,NEONATE W ECMO,,Relative Weights,"$87,271.04 ",IP,"87,271.04","87,271.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5832,NEONATE W ECMO,,Relative Weights,"$87,459.00 ",IP,"87,459.00","87,459.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5833,NEONATE W ECMO,,Relative Weights,"$148,358.12 ",IP,"148,358.12","148,358.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5834,NEONATE W ECMO,,Relative Weights,"$163,193.83 ",IP,"163,193.83","163,193.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5881,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$67,852.39 ",IP,"67,852.39","67,852.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5882,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$75,391.54 ",IP,"75,391.54","75,391.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5883,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$83,636.16 ",IP,"83,636.16","83,636.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5884,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$133,619.66 ",IP,"133,619.66","133,619.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5891,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$98,896.59 ",IP,"98,896.59","98,896.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5892,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$69,370.87 ",IP,"69,370.87","69,370.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5893,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$63,064.65 ",IP,"63,064.65","63,064.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5894,NEONATE BWT <500G OR GA <24 WEEKS,,Relative Weights,"$11,889.12 ",IP,"11,889.12","11,889.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5911,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$57,344.65 ",IP,"57,344.65","57,344.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5912,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$79,559.04 ",IP,"79,559.04","79,559.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5913,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$85,488.65 ",IP,"85,488.65","85,488.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5914,NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,,Relative Weights,"$110,417.00 ",IP,"110,417.00","110,417.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5931,NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,,Relative Weights,"$37,781.34 ",IP,"37,781.34","37,781.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5932,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$59,330.12 ",IP,"59,330.12","59,330.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5933,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$71,323.01 ",IP,"71,323.01","71,323.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,5934,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$96,423.52 ",IP,"96,423.52","96,423.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6021,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$36,367.31 ",IP,"36,367.31","36,367.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6022,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$43,081.42 ",IP,"43,081.42","43,081.42",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6023,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$56,708.94 ",IP,"56,708.94","56,708.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6024,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$82,218.02 ",IP,"82,218.02","82,218.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6031,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$21,131.62 ",IP,"21,131.62","21,131.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6032,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$31,760.66 ",IP,"31,760.66","31,760.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6033,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,733.18 ",IP,"45,733.18","45,733.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6034,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$71,521.63 ",IP,"71,521.63","71,521.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6071,NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$24,973.02 ",IP,"24,973.02","24,973.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6072,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$31,699.15 ",IP,"31,699.15","31,699.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6073,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$41,632.01 ",IP,"41,632.01","41,632.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6074,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$64,492.07 ",IP,"64,492.07","64,492.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6081,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$16,607.44 ",IP,"16,607.44","16,607.44",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6082,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$23,967.23 ",IP,"23,967.23","23,967.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6083,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$34,646.09 ",IP,"34,646.09","34,646.09",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6084,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$60,788.81 ",IP,"60,788.81","60,788.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6091,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$25,499.11 ",IP,"25,499.11","25,499.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6092,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$27,431.32 ",IP,"27,431.32","27,431.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6093,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$47,002.54 ",IP,"47,002.54","47,002.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6094,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$99,687.62 ",IP,"99,687.62","99,687.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6111,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$12,585.30 ",IP,"12,585.30","12,585.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6112,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$19,393.91 ",IP,"19,393.91","19,393.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6113,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$32,347.92 ",IP,"32,347.92","32,347.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6114,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$58,174.51 ",IP,"58,174.51","58,174.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6121,NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,,Relative Weights,"$16,224.65 ",IP,"16,224.65","16,224.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6122,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$21,637.79 ",IP,"21,637.79","21,637.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6123,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$29,186.22 ",IP,"29,186.22","29,186.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6124,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$42,407.23 ",IP,"42,407.23","42,407.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6131,NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,196.61 ",IP,"13,196.61","13,196.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6132,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$21,189.35 ",IP,"21,189.35","21,189.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6133,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$27,656.40 ",IP,"27,656.40","27,656.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6134,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$47,731.03 ",IP,"47,731.03","47,731.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6141,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,925.34 ",IP,"8,925.34","8,925.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6142,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$15,030.54 ",IP,"15,030.54","15,030.54",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6143,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,580.55 ",IP,"25,580.55","25,580.55",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6144,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,341.79 ",IP,"45,341.79","45,341.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6211,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$6,929.91 ",IP,"6,929.91","6,929.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6212,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$14,367.69 ",IP,"14,367.69","14,367.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6213,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$26,320.72 ",IP,"26,320.72","26,320.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6214,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$49,514.79 ",IP,"49,514.79","49,514.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6221,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$10,129.06 ",IP,"10,129.06","10,129.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6222,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$13,681.47 ",IP,"13,681.47","13,681.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6223,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$17,417.03 ",IP,"17,417.03","17,417.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6224,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$32,501.52 ",IP,"32,501.52","32,501.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6231,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$7,947.73 ",IP,"7,947.73","7,947.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6232,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$11,704.59 ",IP,"11,704.59","11,704.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6233,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$18,604.26 ",IP,"18,604.26","18,604.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6234,NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$29,470.40 ",IP,"29,470.40","29,470.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6251,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,481.72 ",IP,"8,481.72","8,481.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6252,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$12,056.81 ",IP,"12,056.81","12,056.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6253,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$17,253.12 ",IP,"17,253.12","17,253.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6254,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,500.83 ",IP,"25,500.83","25,500.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6261,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,026.75 ",IP,"1,026.75","1,026.75",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6262,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,832.56 ",IP,"1,832.56","1,832.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6263,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$5,129.99 ",IP,"5,129.99","5,129.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6264,"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$14,511.67 ",IP,"14,511.67","14,511.67",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6301,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$14,642.59 ",IP,"14,642.59","14,642.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6302,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$26,499.41 ",IP,"26,499.41","26,499.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6303,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$44,508.84 ",IP,"44,508.84","44,508.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6304,NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$79,154.59 ",IP,"79,154.59","79,154.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6311,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$11,884.65 ",IP,"11,884.65","11,884.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6312,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$19,077.77 ",IP,"19,077.77","19,077.77",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6313,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$33,764.00 ",IP,"33,764.00","33,764.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6314,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$74,464.79 ",IP,"74,464.79","74,464.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6331,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$2,688.87 ",IP,"2,688.87","2,688.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6332,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$7,851.51 ",IP,"7,851.51","7,851.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6333,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$17,713.92 ",IP,"17,713.92","17,713.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6334,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$44,843.19 ",IP,"44,843.19","44,843.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6341,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$4,461.64 ",IP,"4,461.64","4,461.64",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6342,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$7,881.41 ",IP,"7,881.41","7,881.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6343,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$11,444.81 ",IP,"11,444.81","11,444.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6344,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$28,806.17 ",IP,"28,806.17","28,806.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6361,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$4,375.39 ",IP,"4,375.39","4,375.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6362,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$6,615.83 ",IP,"6,615.83","6,615.83",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6363,NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,140.60 ",IP,"13,140.60","13,140.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6364,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$22,289.30 ",IP,"22,289.30","22,289.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6391,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$4,122.14 ",IP,"4,122.14","4,122.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6392,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$7,440.19 ",IP,"7,440.19","7,440.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6393,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$11,681.22 ",IP,"11,681.22","11,681.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6394,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$20,735.08 ",IP,"20,735.08","20,735.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6401,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$571.11 ,IP,571.11,571.11,,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6402,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$900.64 ,IP,900.64,900.64,,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6403,"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$2,228.41 ",IP,"2,228.41","2,228.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6404,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$13,890.74 ",IP,"13,890.74","13,890.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6501,SPLENECTOMY,,Relative Weights,"$6,304.16 ",IP,"6,304.16","6,304.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6502,SPLENECTOMY,,Relative Weights,"$8,491.69 ",IP,"8,491.69","8,491.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6503,SPLENECTOMY,,Relative Weights,"$13,332.00 ",IP,"13,332.00","13,332.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6504,SPLENECTOMY,,Relative Weights,"$23,483.06 ",IP,"23,483.06","23,483.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6511,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6512,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$7,236.76 ",IP,"7,236.76","7,236.76",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6513,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$10,916.31 ",IP,"10,916.31","10,916.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6514,OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,,Relative Weights,"$33,538.24 ",IP,"33,538.24","33,538.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6601,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$3,747.59 ",IP,"3,747.59","3,747.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6602,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$4,287.77 ",IP,"4,287.77","4,287.77",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6603,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$6,366.70 ",IP,"6,366.70","6,366.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6604,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$16,194.41 ",IP,"16,194.41","16,194.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6611,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$3,902.56 ",IP,"3,902.56","3,902.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6612,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$5,668.11 ",IP,"5,668.11","5,668.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6613,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$9,739.74 ",IP,"9,739.74","9,739.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6614,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$15,545.30 ",IP,"15,545.30","15,545.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6621,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$2,821.17 ",IP,"2,821.17","2,821.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6622,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$3,681.27 ",IP,"3,681.27","3,681.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6623,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$5,206.96 ",IP,"5,206.96","5,206.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6624,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$10,694.33 ",IP,"10,694.33","10,694.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6631,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$2,701.59 ",IP,"2,701.59","2,701.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6632,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$3,327.33 ",IP,"3,327.33","3,327.33",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6633,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$4,391.20 ",IP,"4,391.20","4,391.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6634,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$8,007.52 ",IP,"8,007.52","8,007.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6801,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,740.52 ",IP,"7,740.52","7,740.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6802,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$10,236.62 ",IP,"10,236.62","10,236.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6803,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$16,199.56 ",IP,"16,199.56","16,199.56",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6804,MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,,Relative Weights,"$34,974.94 ",IP,"34,974.94","34,974.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6811,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$6,220.66 ",IP,"6,220.66","6,220.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6812,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,805.46 ",IP,"7,805.46","7,805.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6813,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$13,731.30 ",IP,"13,731.30","13,731.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6814,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$32,311.50 ",IP,"32,311.50","32,311.50",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6901,ACUTE LEUKEMIA,,Relative Weights,"$8,376.23 ",IP,"8,376.23","8,376.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6902,ACUTE LEUKEMIA,,Relative Weights,"$11,965.06 ",IP,"11,965.06","11,965.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6903,ACUTE LEUKEMIA,,Relative Weights,"$18,264.07 ",IP,"18,264.07","18,264.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6904,ACUTE LEUKEMIA,,Relative Weights,"$33,495.63 ",IP,"33,495.63","33,495.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6911,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$6,184.92 ",IP,"6,184.92","6,184.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6912,"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",,Relative Weights,"$6,251.93 ",IP,"6,251.93","6,251.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6913,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$9,090.97 ",IP,"9,090.97","9,090.97",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6914,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$18,806.65 ",IP,"18,806.65","18,806.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6921,RADIOTHERAPY,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6922,RADIOTHERAPY,,Relative Weights,"$8,603.36 ",IP,"8,603.36","8,603.36",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6923,RADIOTHERAPY,,Relative Weights,"$11,232.45 ",IP,"11,232.45","11,232.45",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6924,RADIOTHERAPY,,Relative Weights,"$22,232.95 ",IP,"22,232.95","22,232.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6941,LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$3,669.93 ",IP,"3,669.93","3,669.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6942,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$4,230.04 ",IP,"4,230.04","4,230.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6943,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$5,867.41 ",IP,"5,867.41","5,867.41",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6944,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$11,092.25 ",IP,"11,092.25","11,092.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6951,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$3,844.14 ",IP,"3,844.14","3,844.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6952,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$4,908.70 ",IP,"4,908.70","4,908.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6953,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$11,375.74 ",IP,"11,375.74","11,375.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6954,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$32,868.17 ",IP,"32,868.17","32,868.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6961,OTHER CHEMOTHERAPY,,Relative Weights,"$4,174.03 ",IP,"4,174.03","4,174.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6962,OTHER CHEMOTHERAPY,,Relative Weights,"$5,397.68 ",IP,"5,397.68","5,397.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6963,OTHER CHEMOTHERAPY,,Relative Weights,"$7,757.01 ",IP,"7,757.01","7,757.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,6964,OTHER CHEMOTHERAPY,,Relative Weights,"$17,845.53 ",IP,"17,845.53","17,845.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7101,INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,,Relative Weights,"$5,318.64 ",IP,"5,318.64","5,318.64",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7102,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$7,922.30 ",IP,"7,922.30","7,922.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7103,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$12,117.63 ",IP,"12,117.63","12,117.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7104,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$24,582.32 ",IP,"24,582.32","24,582.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7111,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$5,432.73 ",IP,"5,432.73","5,432.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7112,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$7,124.05 ",IP,"7,124.05","7,124.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7113,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$12,166.42 ",IP,"12,166.42","12,166.42",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7114,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$25,010.82 ",IP,"25,010.82","25,010.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7201,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$2,801.24 ",IP,"2,801.24","2,801.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7202,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$3,678.52 ",IP,"3,678.52","3,678.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7203,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$5,399.74 ",IP,"5,399.74","5,399.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7204,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$10,740.72 ",IP,"10,740.72","10,740.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7211,"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",,Relative Weights,"$2,917.38 ",IP,"2,917.38","2,917.38",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7212,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$3,837.27 ",IP,"3,837.27","3,837.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7213,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$6,182.18 ",IP,"6,182.18","6,182.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7214,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$12,158.86 ",IP,"12,158.86","12,158.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7221,FEVER,,Relative Weights,"$1,952.14 ",IP,"1,952.14","1,952.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7222,FEVER,,Relative Weights,"$2,920.13 ",IP,"2,920.13","2,920.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7223,FEVER,,Relative Weights,"$3,952.39 ",IP,"3,952.39","3,952.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7224,FEVER,,Relative Weights,"$6,941.25 ",IP,"6,941.25","6,941.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7231,VIRAL ILLNESS,,Relative Weights,"$1,908.50 ",IP,"1,908.50","1,908.50",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7232,VIRAL ILLNESS,,Relative Weights,"$2,685.44 ",IP,"2,685.44","2,685.44",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7233,VIRAL ILLNESS,,Relative Weights,"$4,131.07 ",IP,"4,131.07","4,131.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7234,VIRAL ILLNESS,,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7241,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,048.31 ",IP,"3,048.31","3,048.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7242,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,655.49 ",IP,"3,655.49","3,655.49",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7243,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$5,820.68 ",IP,"5,820.68","5,820.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7244,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$13,099.02 ",IP,"13,099.02","13,099.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7401,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,032.70 ",IP,"6,032.70","6,032.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7402,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,703.46 ",IP,"6,703.46","6,703.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7403,MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,,Relative Weights,"$13,324.79 ",IP,"13,324.79","13,324.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7404,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$26,668.81 ",IP,"26,668.81","26,668.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7501,SCHIZOPHRENIA,,Relative Weights,"$2,530.12 ",IP,"2,530.12","2,530.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7502,SCHIZOPHRENIA,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7503,SCHIZOPHRENIA,,Relative Weights,"$4,799.08 ",IP,"4,799.08","4,799.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7504,SCHIZOPHRENIA,,Relative Weights,"$13,473.58 ",IP,"13,473.58","13,473.58",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7511,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$1,760.40 ",IP,"1,760.40","1,760.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7512,MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,,Relative Weights,"$2,237.01 ",IP,"2,237.01","2,237.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7513,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$3,773.70 ",IP,"3,773.70","3,773.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7514,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$8,518.14 ",IP,"8,518.14","8,518.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7521,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$1,687.20 ",IP,"1,687.20","1,687.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7522,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$2,102.30 ",IP,"2,102.30","2,102.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7523,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$3,885.72 ",IP,"3,885.72","3,885.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7524,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$13,737.14 ",IP,"13,737.14","13,737.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7531,BIPOLAR DISORDERS,,Relative Weights,"$1,873.11 ",IP,"1,873.11","1,873.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7532,BIPOLAR DISORDERS,,Relative Weights,"$2,183.40 ",IP,"2,183.40","2,183.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7533,BIPOLAR DISORDERS,,Relative Weights,"$3,541.07 ",IP,"3,541.07","3,541.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7534,BIPOLAR DISORDERS,,Relative Weights,"$10,043.84 ",IP,"10,043.84","10,043.84",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7541,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$1,523.64 ",IP,"1,523.64","1,523.64",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7542,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$2,007.46 ",IP,"2,007.46","2,007.46",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7543,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$3,012.23 ",IP,"3,012.23","3,012.23",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7544,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$7,979.68 ",IP,"7,979.68","7,979.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7551,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$1,532.57 ",IP,"1,532.57","1,532.57",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7552,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$2,506.06 ",IP,"2,506.06","2,506.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7553,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$3,538.32 ",IP,"3,538.32","3,538.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7554,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$6,118.26 ",IP,"6,118.26","6,118.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7561,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$2,496.79 ",IP,"2,496.79","2,496.79",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7562,ACUTE ANXIETY & DELIRIUM STATES,,Relative Weights,"$3,057.58 ",IP,"3,057.58","3,057.58",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7563,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$3,397.43 ",IP,"3,397.43","3,397.43",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7564,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$7,384.52 ",IP,"7,384.52","7,384.52",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7571,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$2,504.35 ",IP,"2,504.35","2,504.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7572,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$3,161.02 ",IP,"3,161.02","3,161.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7573,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$5,750.24 ",IP,"5,750.24","5,750.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7574,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$15,933.94 ",IP,"15,933.94","15,933.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7581,BEHAVIORAL DISORDERS,,Relative Weights,"$2,326.35 ",IP,"2,326.35","2,326.35",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7582,BEHAVIORAL DISORDERS,,Relative Weights,"$2,881.65 ",IP,"2,881.65","2,881.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7583,BEHAVIORAL DISORDERS,,Relative Weights,"$4,037.26 ",IP,"4,037.26","4,037.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7584,BEHAVIORAL DISORDERS,,Relative Weights,"$5,464.00 ",IP,"5,464.00","5,464.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7591,EATING DISORDERS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7592,EATING DISORDERS,,Relative Weights,"$5,955.04 ",IP,"5,955.04","5,955.04",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7593,EATING DISORDERS,,Relative Weights,"$9,440.78 ",IP,"9,440.78","9,440.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7594,EATING DISORDERS,,Relative Weights,"$12,954.01 ",IP,"12,954.01","12,954.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7601,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$2,553.48 ",IP,"2,553.48","2,553.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7602,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$3,467.19 ",IP,"3,467.19","3,467.19",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7603,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$6,902.07 ",IP,"6,902.07","6,902.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7604,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$12,546.82 ",IP,"12,546.82","12,546.82",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7701,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$1,041.53 ",IP,"1,041.53","1,041.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7702,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$1,522.95 ",IP,"1,522.95","1,522.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7703,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$2,633.89 ",IP,"2,633.89","2,633.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7704,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$6,153.65 ",IP,"6,153.65","6,153.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7721,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$2,743.85 ",IP,"2,743.85","2,743.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7722,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$3,502.58 ",IP,"3,502.58","3,502.58",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7723,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$4,241.72 ",IP,"4,241.72","4,241.72",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7724,ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7731,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,275.88 ",IP,"1,275.88","1,275.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7732,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,881.01 ",IP,"1,881.01","1,881.01",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7733,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$3,476.12 ",IP,"3,476.12","3,476.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7734,OPIOID ABUSE & DEPENDENCE,,Relative Weights,"$9,565.86 ",IP,"9,565.86","9,565.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7741,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,761.43 ",IP,"1,761.43","1,761.43",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7742,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,956.95 ",IP,"1,956.95","1,956.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7743,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$3,314.62 ",IP,"3,314.62","3,314.62",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7744,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$9,105.40 ",IP,"9,105.40","9,105.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7751,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$1,741.50 ",IP,"1,741.50","1,741.50",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7752,ALCOHOL ABUSE & DEPENDENCE,,Relative Weights,"$2,441.81 ",IP,"2,441.81","2,441.81",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7753,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$3,986.06 ",IP,"3,986.06","3,986.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7754,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$10,751.37 ",IP,"10,751.37","10,751.37",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7761,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$2,414.66 ",IP,"2,414.66","2,414.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7762,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7763,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$4,175.40 ",IP,"4,175.40","4,175.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7764,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$7,699.28 ",IP,"7,699.28","7,699.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7921,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,773.51 ",IP,"7,773.51","7,773.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7922,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$8,931.53 ",IP,"8,931.53","8,931.53",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7923,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$13,005.21 ",IP,"13,005.21","13,005.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7924,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$27,591.45 ",IP,"27,591.45","27,591.45",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7931,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$4,608.37 ",IP,"4,608.37","4,608.37",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7932,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$6,350.90 ",IP,"6,350.90","6,350.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7933,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$9,808.12 ",IP,"9,808.12","9,808.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7934,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$20,177.03 ",IP,"20,177.03","20,177.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7941,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,990.87 ",IP,"3,990.87","3,990.87",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7942,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,327.92 ",IP,"5,327.92","5,327.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7943,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,911.30 ",IP,"7,911.30","7,911.30",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,7944,NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$16,457.28 ",IP,"16,457.28","16,457.28",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8101,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$2,594.03 ",IP,"2,594.03","2,594.03",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8102,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$3,420.11 ",IP,"3,420.11","3,420.11",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8103,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$5,351.98 ",IP,"5,351.98","5,351.98",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8104,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$10,772.68 ",IP,"10,772.68","10,772.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8111,ALLERGIC REACTIONS,,Relative Weights,"$1,582.40 ",IP,"1,582.40","1,582.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8112,ALLERGIC REACTIONS,,Relative Weights,"$2,325.66 ",IP,"2,325.66","2,325.66",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8113,ALLERGIC REACTIONS,,Relative Weights,"$4,003.24 ",IP,"4,003.24","4,003.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8114,ALLERGIC REACTIONS,,Relative Weights,"$9,358.65 ",IP,"9,358.65","9,358.65",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8121,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$1,778.95 ",IP,"1,778.95","1,778.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8122,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$2,471.70 ",IP,"2,471.70","2,471.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8123,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$3,713.91 ",IP,"3,713.91","3,713.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8124,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$7,487.95 ",IP,"7,487.95","7,487.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8131,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$2,963.09 ",IP,"2,963.09","2,963.09",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8132,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,546.91 ",IP,"3,546.91","3,546.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8133,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,048.90 ",IP,"5,048.90","5,048.90",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8134,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$10,108.45 ",IP,"10,108.45","10,108.45",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8151,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$2,225.32 ",IP,"2,225.32","2,225.32",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8152,"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",,Relative Weights,"$3,062.74 ",IP,"3,062.74","3,062.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8153,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$5,006.29 ",IP,"5,006.29","5,006.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8154,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$14,243.99 ",IP,"14,243.99","14,243.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8161,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$2,832.85 ",IP,"2,832.85","2,832.85",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8162,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$3,147.27 ",IP,"3,147.27","3,147.27",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8163,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$3,543.13 ",IP,"3,543.13","3,543.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8164,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$7,485.21 ",IP,"7,485.21","7,485.21",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8171,OVERDOSE,,Relative Weights,"$1,970.70 ",IP,"1,970.70","1,970.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8172,OVERDOSE,,Relative Weights,"$2,320.16 ",IP,"2,320.16","2,320.16",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8173,OVERDOSE,,Relative Weights,"$3,714.94 ",IP,"3,714.94","3,714.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8174,OVERDOSE,,Relative Weights,"$7,902.37 ",IP,"7,902.37","7,902.37",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8411,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$22,662.13 ",IP,"22,662.13","22,662.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8412,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$23,053.18 ",IP,"23,053.18","23,053.18",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8413,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$35,475.26 ",IP,"35,475.26","35,475.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8414,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$76,935.80 ",IP,"76,935.80","76,935.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8421,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$7,378.34 ",IP,"7,378.34","7,378.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8422,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$11,298.08 ",IP,"11,298.08","11,298.08",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8423,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$20,251.94 ",IP,"20,251.94","20,251.94",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8424,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$47,998.02 ",IP,"47,998.02","47,998.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8431,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,499.14 ",IP,"3,499.14","3,499.14",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8432,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,888.47 ",IP,"3,888.47","3,888.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8433,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$4,320.07 ",IP,"4,320.07","4,320.07",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8434,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$12,575.34 ",IP,"12,575.34","12,575.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8441,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$2,201.96 ",IP,"2,201.96","2,201.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8442,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,652.06 ",IP,"3,652.06","3,652.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8443,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$7,050.86 ",IP,"7,050.86","7,050.86",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8444,PARTIAL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$19,183.95 ",IP,"19,183.95","19,183.95",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8501,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$9,879.93 ",IP,"9,879.93","9,879.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8502,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$12,498.36 ",IP,"12,498.36","12,498.36",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8503,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$15,265.59 ",IP,"15,265.59","15,265.59",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8504,"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",,Relative Weights,"$33,306.29 ",IP,"33,306.29","33,306.29",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8601,REHABILITATION,REHABILITATION,Relative Weights,"$2,725.99 ",IP,"2,725.99","2,725.99",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8602,REHABILITATION,REHABILITATION,Relative Weights,"$2,784.40 ",IP,"2,784.40","2,784.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8603,REHABILITATION,REHABILITATION,Relative Weights,"$4,569.88 ",IP,"4,569.88","4,569.88",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8604,REHABILITATION,REHABILITATION,Relative Weights,"$7,353.25 ",IP,"7,353.25","7,353.25",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8611,"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",,Relative Weights,"$2,528.74 ",IP,"2,528.74","2,528.74",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8612,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$3,061.36 ",IP,"3,061.36","3,061.36",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8613,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$4,043.10 ",IP,"4,043.10","4,043.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8614,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$7,783.47 ",IP,"7,783.47","7,783.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8621,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$2,738.70 ",IP,"2,738.70","2,738.70",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8622,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$3,392.96 ",IP,"3,392.96","3,392.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8623,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$4,971.92 ",IP,"4,971.92","4,971.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8624,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$9,845.92 ",IP,"9,845.92","9,845.92",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8631,NEONATAL AFTERCARE,,Relative Weights,"$4,260.96 ",IP,"4,260.96","4,260.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8632,NEONATAL AFTERCARE,,Relative Weights,"$10,340.39 ",IP,"10,340.39","10,340.39",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8633,NEONATAL AFTERCARE,,Relative Weights,"$23,505.05 ",IP,"23,505.05","23,505.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8634,NEONATAL AFTERCARE,,Relative Weights,"$48,982.51 ",IP,"48,982.51","48,982.51",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8901,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$3,464.78 ",IP,"3,464.78","3,464.78",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8902,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$4,475.73 ",IP,"4,475.73","4,475.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8903,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$6,306.22 ",IP,"6,306.22","6,306.22",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8904,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$13,523.40 ",IP,"13,523.40","13,523.40",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8921,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$3,450.69 ",IP,"3,450.69","3,450.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8922,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,178.15 ",IP,"4,178.15","4,178.15",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8923,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,816.26 ",IP,"4,816.26","4,816.26",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8924,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$8,453.20 ",IP,"8,453.20","8,453.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8931,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$2,817.73 ",IP,"2,817.73","2,817.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8932,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$4,010.80 ",IP,"4,010.80","4,010.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8933,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$5,201.12 ",IP,"5,201.12","5,201.12",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8934,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$9,134.61 ",IP,"9,134.61","9,134.61",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8941,HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,,Relative Weights,"$2,969.96 ",IP,"2,969.96","2,969.96",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8942,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$3,496.05 ",IP,"3,496.05","3,496.05",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8943,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$4,518.34 ",IP,"4,518.34","4,518.34",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,8944,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$6,751.91 ",IP,"6,751.91","6,751.91",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9101,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$13,920.63 ",IP,"13,920.63","13,920.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9102,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$15,317.47 ",IP,"15,317.47","15,317.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9103,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$18,619.37 ",IP,"18,619.37","18,619.37",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9104,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$36,457.00 ",IP,"36,457.00","36,457.00",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9111,EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$7,838.80 ",IP,"7,838.80","7,838.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9112,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$10,303.63 ",IP,"10,303.63","10,303.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9113,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$13,414.47 ",IP,"13,414.47","13,414.47",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9114,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$32,085.73 ",IP,"32,085.73","32,085.73",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9121,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$8,688.93 ",IP,"8,688.93","8,688.93",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9122,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$9,567.24 ",IP,"9,567.24","9,567.24",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9123,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$14,948.76 ",IP,"14,948.76","14,948.76",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9124,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$30,211.60 ",IP,"30,211.60","30,211.60",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9301,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$3,875.76 ",IP,"3,875.76","3,875.76",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9302,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$4,609.06 ",IP,"4,609.06","4,609.06",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9303,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$7,139.17 ",IP,"7,139.17","7,139.17",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9304,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$15,709.89 ",IP,"15,709.89","15,709.89",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9501,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,265.63 ",IP,"7,265.63","7,265.63",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9502,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,410.20 ",IP,"9,410.20","9,410.20",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9503,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$12,679.80 ",IP,"12,679.80","12,679.80",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9504,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$27,388.02 ",IP,"27,388.02","27,388.02",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9511,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,641.31 ",IP,"5,641.31","5,641.31",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9512,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,394.49 ",IP,"7,394.49","7,394.49",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9513,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$11,184.68 ",IP,"11,184.68","11,184.68",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9514,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$22,584.13 ",IP,"22,584.13","22,584.13",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9521,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,663.69 ",IP,"4,663.69","4,663.69",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9522,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,212.76 ",IP,"6,212.76","6,212.76",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9523,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,852.10 ",IP,"9,852.10","9,852.10",,,,,,,,,,,,
Aetna Better Health Medicaid,DRG,9524,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$20,519.28 ",IP,"20,519.28","20,519.28",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,100,Anesth salivary gland,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,102,Anesth repair of cleft lip,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,103,Anesth blepharoplasty,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,104,Anesth electroshock,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,120,Anesth ear surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,124,Anesth ear exam,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,126,Anesth tympanotomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,140,Anesth procedures on eye,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,142,Anesth lens surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,144,Anesth corneal transplant,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,145,Anesth vitreoretinal surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,147,Anesth iridectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,148,Anesth eye exam,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,160,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,162,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,164,Anesth biopsy of nose,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,170,Anesth procedure on mouth,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,172,Anesth cleft palate repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,174,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,176,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,190,Anesth face/skull bone surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,192,Anesth facial bone surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,210,Anesth cranial surg nos,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,211,Anesth cran surg hemotoma,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,212,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,214,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,215,Anesth skull repair/fract,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,216,Anesth head vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,218,Anesth special head surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,220,Anesth intrcrn nerve,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,222,Anesth head nerve surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,300,Anesth head/neck/ptrunk,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,320,Anesth neck organ 1yr/>,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,322,Anesth biopsy of thyroid,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,326,Anesth larynx/trach < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,350,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,352,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,400,Anesth skin ext/per/atrunk,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,402,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,404,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,406,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,410,Anesth correct heart rhythm,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,450,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,454,Anesth collar bone biopsy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,470,Anesth removal of rib,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,472,Anesth chest wall repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,474,Anesth surgery of rib,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,500,Anesth esophageal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,520,Anesth chest procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,522,Anesth chest lining biopsy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,524,Anesth chest drainage,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,528,Anes mediascpy & dx thorscpy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,529,Anes medscpy&thorscpy 1 lung,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,530,Anesth pacemaker insertion,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,532,Anesth vascular access,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,534,Anesth cardioverter/defib,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,537,Anesth cardiac electrophys,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,539,Anesth trach-bronch reconst,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,540,Anesth chest surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,541,Anesth one lung ventilation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,542,Anesthesia removal pleura,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,546,Anesth lung chest wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,548,Anesth trachea bronchi surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,550,Anesth sternal debridement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,560,Anesth heart surg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,561,Anesth heart surg <1 yr,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,562,Anesth hrt surg w/pmp age 1+,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,563,Anesth heart surg w/arrest,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,566,Anesth cabg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,567,Anesth cabg w/pump,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,580,Anesth heart/lung transplnt,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,600,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,604,Anesth sitting procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,620,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,625,Anes spine tranthor w/o vent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,626,Anes spine transthor w/vent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,630,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,632,Anesth removal of nerves,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,635,Anesth lumbar puncture,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,640,Anesth spine manipulation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,670,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,700,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,702,Anesth for liver biopsy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,730,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,731,Anes upr gi ndsc px nos,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,732,Anes upr gi ndsc px ercp,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,740,Anesth upper gi visualize,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,750,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,752,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,754,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,756,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,770,Anesth blood vessel repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,790,Anesth surg upper abdomen,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,792,Anesth hemorr/excise liver,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,794,Anesth pancreas removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,796,Anesth for liver transplant,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,797,Anesth surgery for obesity,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,800,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,802,Anesth fat layer removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,810,Anesth low intestine scope,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,811,Anes lwr intst ndsc nos,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,812,Anes lwr intst scr colsc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,813,Anes upr lwr gi ndsc px,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,820,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,830,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,832,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,834,Anesth hernia repair < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,836,Anesth hernia repair preemie,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,840,Anesth surg lower abdomen,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,842,Anesth amniocentesis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,844,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,846,Anesth hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,848,Anesth pelvic organ surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,851,Anesth tubal ligation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,860,Anesth surgery of abdomen,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,862,Anesth kidney/ureter surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,864,Anesth removal of bladder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,865,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,866,Anesth removal of adrenal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,868,Anesth kidney transplant,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,870,Anesth bladder stone surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,872,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,873,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,880,Anesth abdomen vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,882,Anesth major vein ligation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,902,Anesth anorectal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,904,Anesth perineal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,906,Anesth removal of vulva,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,908,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,910,Anesth bladder surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,912,Anesth bladder tumor surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,914,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,916,Anesth bleeding control,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,918,Anesth stone removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,920,Anesth genitalia surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,921,Anesth vasectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,922,Anesth sperm duct surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,924,Anesth testis exploration,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,926,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,928,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,930,Anesth testis suspension,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,932,Anesth amputation of penis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,934,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,936,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,938,Anesth insert penis device,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,940,Anesth vaginal procedures,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,942,Anesth surg on vag/urethral,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,944,Anesth vaginal hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,948,Anesth repair of cervix,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,950,Anesth vaginal endoscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,952,Anesth hysteroscope/graph,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1112,Anesth bone aspirate/bx,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1120,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1130,Anesth body cast procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1140,Anesth amputation at pelvis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1150,Anesth pelvic tumor surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1160,Anesth pelvis procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1170,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1173,Anesth fx repair pelvis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1180,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1190,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1200,Anesth hip joint procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1202,Anesth arthroscopy of hip,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1210,Anesth hip joint surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1212,Anesth hip disarticulation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1214,Anesth hip arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1215,Anesth revise hip repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1220,Anesth procedure on femur,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1230,Anesth surgery of femur,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1232,Anesth amputation of femur,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1234,Anesth radical femur surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1250,Anesth upper leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1260,Anesth upper leg veins surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1270,Anesth thigh arteries surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1272,Anesth femoral artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1274,Anesth femoral embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1320,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1340,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1360,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1380,Anesth knee joint procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1382,Anesth dx knee arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1390,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1392,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1400,Anesth knee joint surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1402,Anesth knee arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1404,Anesth amputation at knee,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1420,Anesth knee joint casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1430,Anesth knee veins surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1432,Anesth knee vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1440,Anesth knee arteries surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1442,Anesth knee artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1444,Anesth knee artery repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1462,Anesth lower leg procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1464,Anesth ankle/ft arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1470,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1472,Anesth achilles tendon surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1474,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1480,Anesth lower leg bone surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1482,Anesth radical leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1484,Anesth lower leg revision,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1486,Anesth ankle replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1490,Anesth lower leg casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1500,Anesth leg arteries surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1502,Anesth lwr leg embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1520,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1522,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1610,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1620,Anesth shoulder procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1622,Anes dx shoulder arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1630,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1634,Anesth shoulder joint amput,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1636,Anesth forequarter amput,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1638,Anesth shoulder replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1650,Anesth shoulder artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1652,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1654,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1656,Anesth arm-leg vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1670,Anesth shoulder vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1680,Anesth shoulder casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1682,Anesth airplane cast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1710,Anesth elbow area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1712,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1714,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1716,Anesth biceps tendon repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1730,Anesth uppr arm procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1732,Anesth dx elbow arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1740,Anesth upper arm surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1742,Anesth humerus surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1744,Anesth humerus repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1756,Anesth radical humerus surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1758,Anesth humeral lesion surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1760,Anesth elbow replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1770,Anesth uppr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1772,Anesth uppr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1780,Anesth upper arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1782,Anesth uppr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1810,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1820,Anesth lower arm procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1829,Anesth dx wrist arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1830,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1832,Anesth wrist replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1840,Anesth lwr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1842,Anesth lwr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1844,Anesth vascular shunt surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1850,Anesth lower arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1852,Anesth lwr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1860,Anesth lower arm casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1916,Anesth dx arteriography,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1920,Anesth catheterize heart,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1922,Anesth cat or mri scan,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1924,Anes ther interven rad artrl,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1925,Anes ther interven rad card,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1926,Anes tx interv rad hrt/cran,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1930,Anes ther interven rad vein,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1931,Anes ther interven rad tips,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1932,Anes tx interv rad th vein,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1933,Anes tx interv rad cran vein,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1935,Anesth perc img dx sp proc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1936,Anesth perc img tx sp proc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1951,Anesth burn less 4 percent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1952,Anesth burn 4-9 percent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1953,Anesth burn each 9 percent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1958,Anesth antepartum manipul,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1960,Anesth vaginal delivery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1961,Anesth cs delivery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1962,Anesth emer hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1963,Anesth cs hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1965,Anesth inc/missed ab proc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1966,Anesth induced ab procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1967,Anesth/analg vag delivery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1968,Anes/analg cs deliver add-on,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1969,Anesth/analg cs hyst add-on,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1991,Anesth nerve block/inj,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1992,Anesth n block/inj prone,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1996,Hosp manage cont drug admin,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,1999,Unlisted anesth procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10004,Fna bx w/o img gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10005,Fna bx w/us gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10006,Fna bx w/us gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10007,Fna bx w/fluor gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10008,Fna bx w/fluor gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10009,Fna bx w/ct gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10010,Fna bx w/ct gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10011,Fna bx w/mr gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10012,Fna bx w/mr gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10021,Fna bx w/o img gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10022,Fna w/image,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10030,Guide cathet fluid drainage,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10040,Acne surgery,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10060,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10061,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10080,Drainage of pilonidal cyst,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10081,Drainage of pilonidal cyst,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10120,Remove foreign body,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10121,Remove foreign body,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10140,Drainage of hematoma/fluid,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,10160,Puncture drainage of lesion,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11055,Trim skin lesion,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11056,Trim skin lesions 2 to 4,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11057,Trim skin lesions over 4,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11100,Biopsy skin lesion,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11101,Biopsy skin add-on,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11102,Tangntl bx skin single les,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11103,Tangntl bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11104,Punch bx skin single lesion,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11105,Punch bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11106,Incal bx skn single les,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11107,Incal bx skn ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11200,Removal of skin tags 2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11305,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11306,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11307,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11308,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11310,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11311,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11312,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11313,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11406,Exc tr-ext b9+marg >4.0 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11446,Exc face-mm b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11450,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11451,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11462,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11463,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11470,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11471,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11606,Exc tr-ext mal+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11719,Trim nail(s) any number,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11720,Debride nail 1-5,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11721,Debride nail 6 or more,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11730,Removal of nail plate,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11732,Remove nail plate add-on,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11740,Drain blood from under nail,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11750,Removal of nail bed,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11752,Remove nail bed/tip,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11755,Biopsy nail unit,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11760,Repair of nail bed,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11762,Reconstruction of nail bed,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11765,Excision of nail fold toe,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11770,Remove pilonidal cyst simple,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11771,Remove pilonidal cyst exten,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11772,Remove pilonidal cyst compl,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11900,Inject skin lesions 7,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11920,Correct skin color 6.0 cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11921,Correct skn color 6.1-20.0cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11922,Correct skin color ea 20.0cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11950,Tx contour defects 1 cc/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11951,Tx contour defects 1.1-5.0cc,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11952,Tx contour defects 5.1-10cc,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11954,Tx contour defects >10.0 cc,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11960,Insert tissue expander(s),General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11971,Rmvl tis xpndr wo insj implt,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11976,Remove contraceptive capsule,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11980,Implant hormone pellet(s),General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11981,Insert drug implant device,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11982,Remove drug implant device,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,11983,Remove/insert drug implant,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13102,Cmplx rpr trunk addl 5cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13122,Cmplx rpr s/a/l addl 5 cm/>,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13133,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,13153,Cmplx rpr e/n/e/l addl 5cm/<,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15050,Skin pinch graft,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15775,Hair trnspl 1-15 punch grfts,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15776,Hair trnspl >15 punch grafts,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15780,Dermabrasion total face,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15781,Dermabrasion segmental face,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15782,Dermabrasion other than face,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15783,Dermabrasion suprfl any site,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15786,Abrasion lesion single,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15787,Abrasion lesions add-on,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15788,Chemical peel face epiderm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15789,Chemical peel face dermal,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15792,Chemical peel nonfacial,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15793,Chemical peel nonfacial,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15819,Plastic surgery neck,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15820,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15821,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15822,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15823,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15824,Removal of forehead wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15825,Removal of neck wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15826,Removal of brow wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15828,Removal of face wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15829,Removal of skin wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15830,Exc skin abd,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15832,Excise excessive skin thigh,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15833,Excise excessive skin leg,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15834,Excise excessive skin hip,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15835,Excise excessive skin buttck,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15836,Excise excessive skin arm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15837,Excise excess skin arm/hand,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15838,Excise excess skin fat pad,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15839,Excise excess skin & tissue,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15847,Exc skin abd add-on,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15850,Remove sutures same surgeon,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15851,Remove sutures diff surgeon,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15876,Suction lipectomy head&neck,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15877,Suction lipectomy trunk,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15878,Suction lipectomy upr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,15879,Suction lipectomy lwr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17000,Destruct premalg lesion,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17003,Destruct premalg les 2-14,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17004,Destroy premal lesions 15/>,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17106,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17107,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17108,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17110,Destruct b9 lesion 1-14,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17111,Destruct lesion 15 or more,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17250,Chem caut of granltj tissue,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17260,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17261,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17262,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17263,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17264,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17266,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17270,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17271,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17272,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17273,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17274,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17276,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17280,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17281,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17282,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17283,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17284,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17286,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17340,Cryotherapy of skin,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17360,Skin peel therapy,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17380,Hair removal by electrolysis,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,17999,Skin tissue procedure,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19000,Drainage of breast lesion,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19001,Drain breast lesion add-on,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19020,Incision of breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19081,Bx breast 1st lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19082,Bx breast add lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19083,Bx breast 1st lesion us imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19084,Bx breast add lesion us imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19085,Bx breast 1st lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19086,Bx breast add lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19100,Bx breast percut w/o image,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19101,Biopsy of breast open,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19105,Cryosurg ablate fa each,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19110,Nipple exploration,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19112,Excise breast duct fistula,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19120,Removal of breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19125,Excision breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19126,Excision addl breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19294,Prep tum cav iort prtl mast,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19297,Place breast cath for rad,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19298,Place breast rad tube/caths,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19300,Removal of breast tissue,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19301,Partial mastectomy,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19302,P-mastectomy w/ln removal,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19303,Mast simple complete,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19304,Mast subq,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19305,Mast radical,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19306,Mast rad urban type,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19307,Mast mod rad,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19316,Suspension of breast,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19318,Breast reduction,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19324,Enlarge breast,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19325,Breast augmentation w/implt,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19328,Rmvl intact breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19330,Rmvl ruptured breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19340,Insj breast implt sm d mast,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19342,Insj/rplcmt brst implt sep d,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19350,Breast reconstruction,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19355,Correct inverted nipple(s),General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19357,Tiss xpndr plmt brst rcnstj,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19361,Brst rcnstj latsms drsi flap,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19364,Brst rcnstj free flap,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19366,Breast reconstruction,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19367,Brst rcnstj 1 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19368,Brst rcnstj 1pdcl tram anast,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19369,Brst rcnstj 2 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19370,Revj peri-implt capsule brst,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19371,Peri-implt capslc brst compl,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19380,Revj reconstructed breast,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19396,Design custom breast implant,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,19499,Breast surgery procedure,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20206,Needle biopsy muscle,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20220,Bone biopsy trocar/needle,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20500,Injection of sinus tract,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20526,Ther injection carp tunnel,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20527,Inj dupuytren cord w/enzyme,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20550,Inj tendon sheath/ligament,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20551,Inj tendon origin/insertion,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20552,Inj trigger point 1/2 muscl,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20553,Inject trigger points 3/>,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20560,Ndl insj w/o njx 1 or 2 musc,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20561,Ndl insj w/o njx 3+ musc,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20600,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20605,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20610,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20612,Aspirate/inj ganglion cyst,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20822,Replantation digit complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20824,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20827,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20957,Mt bone graft microvasc,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20972,Bone/skin graft metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20973,Bone/skin graft great toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,20999,Musculoskeletal surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21010,Incision of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21025,Excision of bone lower jaw,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21030,Excise max/zygoma b9 tumor,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21031,Remove exostosis mandible,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21032,Remove exostosis maxilla,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21034,Excise max/zygoma mal tumor,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21040,Excise mandible lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21044,Removal of jaw bone lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21045,Extensive jaw surgery,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21046,Remove mandible cyst complex,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21047,Excise lwr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21048,Remove maxilla cyst complex,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21049,Excis uppr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21050,Removal of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21060,Remove jaw joint cartilage,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21070,Remove coronoid process,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21073,Mnpj of tmj w/anesth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21076,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21077,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21079,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21080,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21081,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21082,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21083,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21084,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21085,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21086,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21087,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21088,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21089,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21100,Maxillofacial fixation,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21110,Interdental fixation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21120,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21121,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21122,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21123,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21125,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21127,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21138,Reduction of forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21172,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21175,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21193,Reconst lwr jaw w/o graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21195,Reconst lwr jaw w/o fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21196,Reconst lwr jaw w/fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21198,Reconstr lwr jaw segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21199,Reconstr lwr jaw w/advance,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21206,Reconstruct upper jaw bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21215,Lower jaw bone graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21235,Ear cartilage graft,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21240,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21242,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21243,Reconstruction of jaw joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21244,Reconstruction of lower jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21245,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21246,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21248,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21249,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21270,Augmentation cheek bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21280,Revision of eyelid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21282,Revision of eyelid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21295,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21296,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21315,Closed tx nose fx w/o stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21320,Closed tx nose fx w/ stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21336,Open tx septal fx w/wo stabj,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21337,Closed tx septal&nose fx,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21345,Closed tx nose/jaw fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21346,Opn tx nasomax fx w/fixj,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21400,Closed tx orbit w/o manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21401,Closed tx orbit w/manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21421,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21422,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21440,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21445,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21450,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21451,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21452,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21453,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21454,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21461,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21462,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21465,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21470,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21485,Reset dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21490,Repair dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21495,Treat hyoid bone fracture,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21497,Interdental wiring,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21685,Hyoid myotomy & suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21805,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21811,Optx of rib fx w/fixj scope,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21812,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21813,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21820,Treat sternum fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,21825,Treat sternum fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,22305,Closed tx spine process fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,22310,Closed tx vert fx w/o manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,22315,Closed tx vert fx w/manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,22505,Manipulation of spine,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,22515,Perq vertebral augmentation,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,22999,Abdomen surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23470,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23472,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23473,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23474,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23500,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23505,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23515,Treat clavicle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23520,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23525,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23530,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23532,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23540,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23545,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23550,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23552,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23570,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23575,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23585,Treat scapula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23600,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23605,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23615,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23616,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23620,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23625,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23630,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23650,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23655,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23660,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23665,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23670,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23675,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23680,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23700,Fixation of shoulder,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,23929,Shoulder surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24300,Manipulate elbow w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24360,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24361,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24362,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24363,Replace elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24365,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24366,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24370,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24371,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24500,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24505,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24515,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24516,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24530,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24535,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24538,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24545,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24546,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24560,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24565,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24566,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24575,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24576,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24577,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24579,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24582,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24586,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24587,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24600,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24605,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24615,Treat elbow dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24620,Treat elbow fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24635,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24640,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24650,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24655,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24665,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24666,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24670,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24675,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24685,Treat ulnar fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,24999,Upper arm/elbow surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25001,Incise flexor carpi radialis,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25111,Remove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25112,Reremove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25136,Remove & graft wrist lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25210,Removal of wrist bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25215,Removal of wrist bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25259,Manipulate wrist w/anesthes,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25315,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25316,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25332,Revise wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25394,Repair carpal bone shorten,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25430,Vasc graft into carpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25431,Repair nonunion carpal bone,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25441,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25442,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25443,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25444,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25445,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25446,Wrist replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25447,Repair wrist joints,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25449,Remove wrist joint implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25500,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25505,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25515,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25520,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25525,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25526,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25530,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25535,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25545,Treat fracture of ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25560,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25565,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25574,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25575,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25600,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25605,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25606,Treat fx distal radial,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25607,Treat fx rad extra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25608,Treat fx rad intra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25609,Treat fx radial 3+ frag,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25622,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25624,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25628,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25630,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25635,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25645,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25650,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25651,Pin ulnar styloid fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25652,Treat fracture ulnar styloid,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25660,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25670,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25671,Pin radioulnar dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25675,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25676,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25680,Treat wrist fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25685,Treat wrist fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25690,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25695,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25820,Fusion of hand bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25825,Fuse hand bones with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25929,Amputation follow-up surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,25999,Forearm or wrist surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26010,Drainage of finger abscess,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26011,Drainage of finger abscess,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26020,Drain hand tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26025,Drainage of palm bursa,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26030,Drainage of palm bursas,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26034,Treat hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26035,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26037,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26040,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26045,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26055,Incise finger tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26060,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26070,Explore/treat hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26075,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26080,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26100,Biopsy hand joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26105,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26110,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26111,Exc hand les sc 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26113,Exc hand tum deep 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26115,Exc hand les sc < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26116,Exc hand tum deep < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26117,Rad resect hand tumor < 3 cm,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26118,Rad resect hand tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26121,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26123,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26125,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26130,Remove wrist joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26135,Revise finger joint each,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26140,Revise finger joint each,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26145,Tendon excision palm/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26160,Remove tendon sheath lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26170,Removal of palm tendon each,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26180,Removal of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26185,Remove finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26200,Remove hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26205,Remove/graft bone lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26210,Removal of finger lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26215,Remove/graft finger lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26230,Partial removal of hand bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26235,Partial removal finger bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26236,Partial removal finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26250,Extensive hand surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26260,Resect prox finger tumor,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26262,Resect distal finger tumor,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26320,Removal of implant from hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26340,Manipulate finger w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26341,Manipulat palm cord post inj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26350,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26352,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26356,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26357,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26358,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26370,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26372,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26373,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26390,Revise hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26392,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26410,Repair hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26412,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26415,Excision hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26416,Graft hand or finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26418,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26420,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26426,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26428,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26432,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26433,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26434,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26437,Realignment of tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26440,Release palm/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26442,Release palm & finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26445,Release hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26449,Release forearm/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26450,Incision of palm tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26455,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26460,Incise hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26471,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26474,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26476,Tendon lengthening,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26477,Tendon shortening,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26478,Lengthening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26479,Shortening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26480,Transplant hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26483,Transplant/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26485,Transplant palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26489,Transplant/graft palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26490,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26492,Tendon transfer with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26494,Hand tendon/muscle transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26496,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26497,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26498,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26499,Revision of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26500,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26502,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26508,Release thumb contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26510,Thumb tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26516,Fusion of knuckle joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26517,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26518,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26520,Release knuckle contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26525,Release finger contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26530,Revise knuckle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26531,Revise knuckle with implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26535,Revise finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26536,Revise/implant finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26540,Repair hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26541,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26542,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26545,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26546,Repair nonunion hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26548,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26550,Construct thumb replacement,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26555,Positional change of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26560,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26561,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26562,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26565,Correct metacarpal flaw,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26567,Correct finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26568,Lengthen metacarpal/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26580,Repair hand deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26587,Reconstruct extra finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26590,Repair finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26591,Repair muscles of hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26593,Release muscles of hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26596,Excision constricting tissue,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26600,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26605,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26607,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26608,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26615,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26641,Treat thumb dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26645,Treat thumb fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26650,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26665,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26670,Treat hand dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26675,Treat hand dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26676,Pin hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26685,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26686,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26700,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26705,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26706,Pin knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26715,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26720,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26725,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26727,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26735,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26740,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26742,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26746,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26750,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26755,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26756,Pin finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26765,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26770,Treat finger dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26775,Treat finger dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26776,Pin finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26785,Treat finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26820,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26841,Fusion of thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26842,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26843,Fusion of hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26844,Fusion/graft of hand joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26850,Fusion of knuckle,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26852,Fusion of knuckle with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26860,Fusion of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26861,Fusion of finger jnt add-on,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26862,Fusion/graft of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26863,Fuse/graft added joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26910,Amputate metacarpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26951,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26952,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,26989,Hand/finger surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27125,Partial hip replacement,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27130,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27132,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27134,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27137,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27138,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27175,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27178,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27181,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27193,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27194,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27197,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27198,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27200,Treat tail bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27202,Treat tail bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27215,Treat pelvic fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27216,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27217,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27218,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27220,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27222,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27226,Treat hip wall fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27227,Treat hip fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27230,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27232,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27235,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27236,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27238,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27240,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27246,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27248,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27250,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27252,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27253,Treat hip dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27256,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27257,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27265,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27266,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27267,Cltx thigh fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27268,Cltx thigh fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27269,Optx thigh fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27275,Manipulation of hip joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27299,Pelvis/hip joint surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27412,Autochondrocyte implant knee,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27415,Osteochondral knee allograft,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27437,Revise kneecap,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27438,Revise kneecap with implant,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27440,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27441,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27442,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27443,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27445,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27446,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27447,Total knee arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27486,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27487,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27500,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27501,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27502,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27503,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27507,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27508,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27509,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27510,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27511,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27513,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27514,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27516,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27517,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27520,Treat kneecap fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27524,Treat kneecap fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27530,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27532,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27535,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27536,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27538,Treat knee fracture(s),Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27540,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27550,Treat knee dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27552,Treat knee dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27560,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27562,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27566,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27570,Fixation of knee joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27599,Leg surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27605,Incision of achilles tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27700,Revision of ankle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27702,Reconstruct ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27703,Reconstruction ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27720,Repair of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27722,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27724,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27726,Repair fibula nonunion,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27750,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27752,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27756,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27758,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27759,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27760,Cltx medial ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27762,Cltx med ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27766,Optx medial ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27767,Cltx post ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27768,Cltx post ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27769,Optx post ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27780,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27781,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27784,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27786,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27788,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27792,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27808,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27810,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27814,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27816,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27818,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27822,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27823,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27824,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27825,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27826,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27827,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27828,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27829,Treat lower leg joint,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27830,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27831,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27832,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27840,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27842,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27846,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27848,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27860,Fixation of ankle joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,27899,Leg/ankle surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28001,Drainage of bursa of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28002,Treatment of foot infection,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28005,Treat foot bone lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28008,Incision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28010,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28011,Incision of toe tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28020,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28022,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28024,Exploration of toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28041,Exc foot/toe tum dep 1.5cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28045,Exc foot/toe tum deep <1.5cm,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28046,Resect foot/toe tumor < 3 cm,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28047,Resect foot/toe tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28050,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28052,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28054,Biopsy of toe joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28055,Neurectomy foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28060,Partial removal foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28062,Removal of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28070,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28072,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28080,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28086,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28088,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28090,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28092,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28100,Removal of ankle/heel lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28102,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28103,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28104,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28106,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28107,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28108,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28110,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28111,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28112,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28113,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28114,Removal of metatarsal heads,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28116,Revision of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28118,Removal of heel bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28119,Removal of heel spur,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28120,Part removal of ankle/heel,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28122,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28124,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28126,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28130,Removal of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28140,Removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28150,Removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28153,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28160,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28171,Resect tarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28173,Resect metatarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28175,Resect phalanx of toe tumor,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28190,Removal of foot foreign body,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28193,Removal of foot foreign body,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28200,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28202,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28208,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28210,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28220,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28222,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28225,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28226,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28230,Incision of foot tendon(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28232,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28234,Incision of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28238,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28240,Release of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28250,Revision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28260,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28261,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28262,Revision of foot and ankle,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28264,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28270,Release of foot contracture,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28272,Release of toe joint each,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28280,Fusion of toes,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28285,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28286,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28288,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28289,Corrj halux rigdus w/o implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28290,Correction of bunion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28291,Corrj halux rigdus w/implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28292,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28293,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28294,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28295,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28296,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28297,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28298,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28299,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28300,Incision of heel bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28302,Incision of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28304,Incision of midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28305,Incise/graft midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28306,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28307,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28308,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28309,Incision of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28310,Revision of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28312,Revision of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28313,Repair deformity of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28315,Removal of sesamoid bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28320,Repair of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28322,Repair of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28340,Resect enlarged toe tissue,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28341,Resect enlarged toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28344,Repair extra toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28345,Repair webbed toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28360,Reconstruct cleft foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28400,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28405,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28406,Treatment of heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28415,Treat heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28420,Treat/graft heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28430,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28435,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28436,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28445,Treat ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28446,Osteochondral talus autogrft,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28450,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28455,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28456,Treat midfoot fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28465,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28470,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28475,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28476,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28485,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28490,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28495,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28496,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28505,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28510,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28515,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28525,Treat toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28530,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28531,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28540,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28545,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28546,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28555,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28570,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28575,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28576,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28585,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28600,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28605,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28606,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28615,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28630,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28635,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28636,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28645,Repair toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28660,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28665,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28666,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28675,Repair of toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28705,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28715,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28725,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28730,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28735,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28737,Revision of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28740,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28750,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28755,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28760,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28805,Amputation thru metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28810,Amputation toe & metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28820,Amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28825,Partial amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28890,Hi enrgy eswt plantar fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,28899,Foot/toes surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29000,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29010,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29015,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29035,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29040,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29044,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29046,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29049,Application of figure eight,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29055,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29058,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29065,Application of long arm cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29075,Application of forearm cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29085,Apply hand/wrist cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29086,Apply finger cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29105,Apply long arm splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29125,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29126,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29130,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29131,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29200,Strapping of chest,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29240,Strapping of shoulder,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29260,Strapping of elbow or wrist,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29280,Strapping of hand or finger,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29305,Application of hip cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29325,Application of hip casts,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29345,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29355,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29358,Apply long leg cast brace,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29365,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29405,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29425,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29435,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29440,Addition of walker to cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29445,Apply rigid leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29450,Application of leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29505,Application long leg splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29515,Application lower leg splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29520,Strapping of hip,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29530,Strapping of knee,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29540,Strapping of ankle and/or ft,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29550,Strapping of toes,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29580,Application of paste boot,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29581,Apply multlay comprs lwr leg,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29582,Apply multlay comprs upr leg,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29583,Apply multlay comprs upr arm,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29584,Appl multlay comprs arm/hand,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29700,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29705,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29710,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29720,Repair of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29730,Windowing of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29740,Wedging of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29750,Wedging of clubfoot cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29799,Casting/strapping procedure,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29800,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29804,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29805,Sho arthrs dx +- synovial bx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29806,Sho arthrs srg capsulorpaphy,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29807,Sho arthrs srg rpr slap les,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29819,Sho arthrs srg rmvl loose/fb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29820,Sho arthrs srg prtl synvct,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29821,Sho arthrs srg compl synvct,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29822,Sho arthrs srg lmtd dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29823,Sho arthrs srg xtnsv dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29824,Sho arthrs srg dstl claviclc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29825,Sho arthrs srg lss&rescj ads,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29826,Sho arthrs srg decompression,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29827,Sho arthrs srg rt8tr cuf rpr,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29828,Sho arthrs srg bicp tenodsis,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29830,Elbow arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29834,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29835,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29836,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29837,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29838,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29840,Wrist arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29843,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29844,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29845,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29846,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29847,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29848,Wrist endoscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29850,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29851,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29855,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29856,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29860,Hip arthroscopy dx,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29861,Hip arthro w/fb removal,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29862,Hip arthr0 w/debridement,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29863,Hip arthr0 w/synovectomy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29866,Autgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29867,Allgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29868,Meniscal trnspl knee w/scpe,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29870,Knee arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29871,Knee arthroscopy/drainage,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29873,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29874,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29875,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29876,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29877,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29879,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29880,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29881,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29882,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29883,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29884,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29885,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29886,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29887,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29888,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29889,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29891,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29892,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29893,Scope plantar fasciotomy,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29894,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29895,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29897,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29898,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29899,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29900,Mcp joint arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29901,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29902,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29904,Subtalar arthro w/fb rmvl,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29905,Subtalar arthro w/exc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29906,Subtalar arthro w/deb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29907,Subtalar arthro w/fusion,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29914,Hip arthro w/femoroplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29915,Hip arthro acetabuloplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29916,Hip arthro w/labral repair,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,29999,Arthroscopy of joint,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30020,Drainage of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30100,Intranasal biopsy,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30110,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30115,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30117,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30118,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30120,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30124,Removal of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30125,Removal of nose lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30130,Excise inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30140,Resect inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30150,Partial removal of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30160,Removal of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30200,Injection treatment of nose,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30220,Insert nasal septal button,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30310,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30320,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30400,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30410,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30420,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30430,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30435,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30450,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30460,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30462,Revision of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30465,Repair nasal stenosis,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30468,Rpr nsl vlv collapse w/implt,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30520,Repair of nasal septum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30540,Repair nasal defect,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30560,Release of nasal adhesions,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30580,Repair upper jaw fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30600,Repair mouth/nose fistula,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30620,Intranasal reconstruction,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30630,Repair nasal septum defect,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30801,Ablate inf turbinate superf,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30802,Ablate inf turbinate submuc,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30915,Ligation nasal sinus artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30920,Ligation upper jaw artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30930,Ther fx nasal inf turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,30999,Nasal surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31000,Irrigation maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31002,Irrigation sphenoid sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31020,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31030,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31032,Explore sinus remove polyps,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31050,Exploration sphenoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31051,Sphenoid sinus surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31070,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31075,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31080,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31081,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31084,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31085,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31086,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31087,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31090,Exploration of sinuses,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31200,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31201,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31205,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31225,Removal of upper jaw,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31233,Nsl/sins ndsc dx max sinusc,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31235,Nsl/sins ndsc dx sphn sinusc,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31237,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31238,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31239,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31240,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31241,Nsl/sins ndsc w/artery lig,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31253,Nsl/sins ndsc total,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31255,Nsl/sins ndsc w/tot ethmdct,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31256,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31257,Nsl/sins ndsc tot w/sphendt,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31267,Endoscopy maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31287,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31288,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31290,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31291,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31292,Nsl/sins ndsc med/inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31293,Nsl/sins ndsc med&inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31294,Nsl/sins ndsc surg on dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31295,Nsl/sins ndsc surg max sins,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31296,Nsl/sins ndsc surg frnt sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31297,Nsl/sins ndsc surg sphn sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31298,Nsl/sins ndsc surg frnt&sphn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31299,Sinus surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31300,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31320,Diagnostic incision larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31375,Partial removal of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31400,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31420,Removal of epiglottis,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31500,Insert emergency airway,General Medicine,Per Unit,$385.17 ,OP,$385.17 ,$385.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31510,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31512,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31513,Injection into vocal cord,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31515,Laryngoscopy for aspiration,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31520,Dx laryngoscopy newborn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31525,Dx laryngoscopy excl nb,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31526,Dx laryngoscopy w/oper scope,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31527,Laryngoscopy for treatment,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31528,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31529,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31530,Laryngoscopy w/fb removal,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31531,Laryngoscopy w/fb & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31535,Laryngoscopy w/biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31536,Laryngoscopy w/bx & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31540,Laryngoscopy w/exc of tumor,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31541,Larynscop w/tumr exc + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31545,Remove vc lesion w/scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31546,Remove vc lesion scope/graft,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31551,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31552,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31553,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31554,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31560,Laryngoscop w/arytenoidectom,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31561,Larynscop remve cart + scop,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31570,Laryngoscope w/vc inj,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31571,Laryngoscop w/vc inj + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31572,Largsc w/laser dstrj les,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31573,Largsc w/ther injection,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31574,Largsc w/njx augmentation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31576,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31577,Largsc w/rmvl foreign bdy(s),Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31578,Largsc w/removal lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31579,Laryngoscopy telescopic,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31580,Laryngoplasty laryngeal web,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31582,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31584,Laryngoplasty fx rdctj fixj,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31587,Laryngoplasty cricoid split,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31588,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31590,Reinnervate larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31591,Laryngoplasty medialization,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31595,Larynx nerve surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31599,Larynx surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31615,Visualization of windpipe,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31622,Dx bronchoscope/wash,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31623,Dx bronchoscope/brush,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31624,Dx bronchoscope/lavage,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31625,Bronchoscopy w/biopsy(s),Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31626,Bronchoscopy w/markers,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31627,Navigational bronchoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31628,Bronchoscopy/lung bx each,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31629,Bronchoscopy/needle bx each,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31632,Bronchoscopy/lung bx addl,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31633,Bronchoscopy/needle bx addl,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31635,Bronchoscopy w/fb removal,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31643,Diag bronchoscope/catheter,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31645,Brnchsc w/ther aspir 1st,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31646,Brnchsc w/ther aspir sbsq,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31720,Clearance of airways,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31725,Clearance of airways,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,31899,Airways surgical procedure,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33206,Insert heart pm atrial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33207,Insert heart pm ventricular,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33208,Insrt heart pm atrial & vent,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33212,Insert pulse gen sngl lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33213,Insert pulse gen dual leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33214,Upgrade of pacemaker system,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33221,Insert pulse gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33224,Insert pacing lead & connect,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33225,L ventric pacing lead add-on,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33226,Reposition l ventric lead,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33227,Remove&replace pm gen singl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33228,Remv&replc pm gen dual lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33229,Remv&replc pm gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33230,Insrt pulse gen w/dual leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33231,Insrt pulse gen w/mult leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33233,Removal of pm generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33240,Insrt pulse gen w/singl lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33241,Remove pulse generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33249,Insj/rplcmt defib w/lead(s),Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33262,Rmvl& replc pulse gen 1 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33270,Ins/rep subq defibrillator,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33274,Tcat insj/rpl perm ldls pm,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33275,Tcat rmvl perm ldls pm w/img,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33282,Implant pat-active ht record,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33285,Insj subq car rhythm mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33289,Tcat impl wrls p-art prs snr,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33889,Artery transpose/endovas taa,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33967,Insert i-aort percut device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33968,Remove aortic assist device,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33990,Insj perq vad l hrt arterial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33991,Insj perq vad l hrt artl&ven,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33992,Rmvl perq left heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33993,Reposg perq r/l hrt vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33995,Insj perq vad r hrt venous,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33997,Rmvl perq right heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,33999,Cardiac surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34001,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34101,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34111,Removal of arm artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34201,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34203,Removal of leg artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34421,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34471,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34490,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34501,Repair valve femoral vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34510,Transposition of vein valve,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34520,Cross-over vein graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34530,Leg vein fusion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34714,Opn fem art expos cndt crtj,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34715,Opn ax/subcla art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34716,Opn ax/subcla art expos cndt,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34812,Opn fem art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,34834,Opn brach art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35011,Repair defect of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35013,Repair artery rupture arm,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35045,Repair defect of arm artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35180,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35184,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35188,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35190,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35201,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35206,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35207,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35226,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35231,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35236,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35256,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35261,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35266,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35301,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35302,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35303,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35304,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35305,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35306,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35321,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35355,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35371,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35372,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35390,Reoperation carotid add-on,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35400,Angioscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35452,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35472,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35694,Art trnsposj subclav carotid,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35697,Reimplant artery each,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35700,Reoperation bypass graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35701,Expl n/flwd surg neck art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35702,Expl n/flwd surg uxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35703,Expl n/flwd surg lxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35721,Exploration femoral artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35741,Exploration popliteal artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35761,Exploration of artery/vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35800,Explore neck vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35820,Explore chest vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35860,Explore limb vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35875,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35876,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35901,Excision graft neck,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,35903,Excision graft extremity,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36005,Injection ext venography,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36010,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36011,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36012,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36013,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36014,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36015,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36100,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36120,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36140,Intro ndl icath upr/lxtr art,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36160,Establish access to aorta,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36200,Place catheter in aorta,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36215,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36216,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36217,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36218,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36221,Place cath thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36222,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36223,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36224,Place cath carotd art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36225,Place cath subclavian art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36226,Place cath vertebral art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36227,Place cath xtrnl carotid,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36228,Place cath intracranial art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36245,Ins cath abd/l-ext art 1st,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36246,Ins cath abd/l-ext art 2nd,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36247,Ins cath abd/l-ext art 3rd,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36248,Ins cath abd/l-ext art addl,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36251,Ins cath ren art 1st unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36252,Ins cath ren art 1st bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36253,Ins cath ren art 2nd+ unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36254,Ins cath ren art 2nd+ bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36260,Insertion of infusion pump,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36299,Vessel injection procedure,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36430,Blood transfusion service,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36440,Bl push transfuse 2 yr/<,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36450,Bl exchange/transfuse nb,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36455,Bl exchange/transfuse non-nb,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36456,Prtl exchange transfuse nb,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36460,Transfusion service fetal,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36465,Njx noncmpnd sclrsnt 1 vein,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36466,Njx noncmpnd sclrsnt mlt vn,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36468,Njx sclrsnt spider veins,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36470,Njx sclrsnt 1 incmptnt vein,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36471,Njx sclrsnt mlt incmptnt vn,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36481,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36500,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36511,Apheresis wbc,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36512,Apheresis rbc,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36513,Apheresis platelets,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36514,Apheresis plasma,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36515,Apheresis adsorp/reinfuse,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36516,Apheresis immunoads slctv,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36522,Photopheresis,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36557,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36558,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36560,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36561,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36563,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36565,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36566,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36581,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36582,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36583,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36593,Declot vascular device,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36620,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36625,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36640,Insertion catheter artery,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36680,Insert needle bone cavity,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36800,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36810,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36815,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36823,Insertion of cannula(s),Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36838,Dist revas ligation hemo,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36860,External cannula declotting,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36903,Intro cath dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36905,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36906,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36907,Balo angiop ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36908,Stent plmt ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,36909,Dialysis circuit embolj,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37145,Revision of circulation,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37182,Insert hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37183,Remove hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37184,Prim art m-thrmbc 1st vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37185,Prim art m-thrmbc sbsq vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37186,Sec art thrombectomy add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37195,Thrombolytic therapy stroke,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37202,Transcatheter therapy infuse,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37215,Transcath stent cca w/eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37216,Transcath stent cca w/o eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37217,Stent placemt retro carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37218,Stent placemt ante carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37220,Iliac revasc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37221,Iliac revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37222,Iliac revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37223,Iliac revasc w/stent add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37224,Fem/popl revas w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37225,Fem/popl revas w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37226,Fem/popl revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37227,Fem/popl revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37228,Tib/per revasc w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37229,Tib/per revasc w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37230,Tib/per revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37231,Tib/per revasc stent & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37232,Tib/per revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37233,Tibper revasc w/ather add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37234,Revsc opn/prq tib/pero stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37235,Tib/per revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37236,Open/perq place stent 1st,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37237,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37238,Open/perq place stent same,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37239,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37241,Vasc embolize/occlude venous,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37242,Vasc embolize/occlude artery,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37243,Vasc embolize/occlude organ,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37244,Vasc embolize/occlude bleed,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37247,Trluml balo angiop addl art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37249,Trluml balo angiop addl vein,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37250,Iv us first vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37251,Iv us each add vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37500,Endoscopy ligate perf veins,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37501,Vascular endoscopy procedure,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37565,Ligation of neck vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37600,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37605,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37606,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37607,Ligation of a-v fistula,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37609,Temporal artery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37615,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37618,Ligation of extremity artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37619,Ligation of inf vena cava,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37650,Revision of major vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37790,Penile venous occlusion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,37799,Vascular surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38102,Removal of spleen total,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38120,Laparoscopy splenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38129,Laparoscope proc spleen,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38205,Harvest allogeneic stem cell,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38206,Harvest auto stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38207,Cryopreserve stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38208,Thaw preserved stem cells,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38209,Wash harvest stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38210,T-cell depletion of harvest,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38211,Tumor cell deplete of harvst,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38212,Rbc depletion of harvest,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38213,Platelet deplete of harvest,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38214,Volume deplete of harvest,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38215,Harvest stem cell concentrte,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38230,Bone marrow harvest allogen,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38232,Bone marrow harvest autolog,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38240,Transplt allo hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38241,Transplt autol hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38242,Transplt allo lymphocytes,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38243,Transplj hematopoietic boost,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38300,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38305,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38308,Incision of lymph channels,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38380,Thoracic duct procedure,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38500,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38505,Needle biopsy lymph nodes,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38510,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38520,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38525,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38530,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38531,Open bx/exc inguinofem nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38542,Explore deep node(s) neck,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38550,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38555,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38562,Removal pelvic lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38570,Laparoscopy lymph node biop,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38571,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38572,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38573,Laps pelvic lymphadec,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38589,Laparoscope proc lymphatic,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38700,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38720,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38724,Removal of lymph nodes neck,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38740,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38745,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38747,Remove abdominal lymph nodes,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38760,Remove groin lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38792,Ra tracer id of sentinl node,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38794,Access thoracic lymph duct,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,38999,Blood/lymph system procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,39545,Revision of diaphragm,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,39599,Diaphragm surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40490,Biopsy of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40500,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40510,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40520,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40525,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40527,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40530,Partial removal of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40650,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40652,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40654,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40799,Lip surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40801,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40805,Removal foreign body mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40806,Incision of lip fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40808,Biopsy of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40810,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40812,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40814,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40816,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40818,Excise oral mucosa for graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40819,Excise lip or cheek fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40820,Treatment of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40830,Repair mouth laceration,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40831,Repair mouth laceration,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40840,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40842,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40843,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40844,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40845,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,40899,Mouth surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41000,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41005,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41006,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41007,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41008,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41009,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41010,Incision of tongue fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41015,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41016,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41017,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41018,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41100,Biopsy of tongue,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41105,Biopsy of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41108,Biopsy of floor of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41110,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41112,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41113,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41114,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41115,Excision of tongue fold,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41116,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41120,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41130,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41135,Tongue and neck surgery,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41150,Tongue mouth jaw surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41500,Fixation of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41510,Tongue to lip surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41512,Tongue suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41520,Reconstruction tongue fold,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41530,Tongue base vol reduction,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41599,Tongue and mouth surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41805,Removal foreign body gum,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41806,Removal foreign body jawbone,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41820,Excision gum each quadrant,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41821,Excision of gum flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41822,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41823,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41825,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41826,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41827,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41828,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41830,Removal of gum tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41850,Treatment of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41870,Gum graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41872,Repair gum,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41874,Repair tooth socket,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,41899,Dental surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42100,Biopsy roof of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42104,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42106,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42107,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42120,Remove palate/lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42140,Excision of uvula,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42160,Treatment mouth roof lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42180,Repair palate,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42182,Repair palate,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42260,Repair nose to lip fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42280,Preparation palate mold,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42281,Insertion palate prosthesis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42299,Palate/uvula surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42300,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42305,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42310,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42320,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42330,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42335,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42340,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42400,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42405,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42408,Excision of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42409,Drainage of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42410,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42415,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42420,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42425,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42426,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42440,Excise submaxillary gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42450,Excise sublingual gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42500,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42505,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42507,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42509,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42510,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42600,Closure of salivary fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42650,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42660,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42665,Ligation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42699,Salivary surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42720,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42725,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42800,Biopsy of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42804,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42806,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42808,Excise pharynx lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42810,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42815,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42820,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42821,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42825,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42826,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42830,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42831,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42835,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42836,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42842,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42844,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42860,Excision of tonsil tags,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42870,Excision of lingual tonsil,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42890,Partial removal of pharynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42892,Revision of pharyngeal walls,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42900,Repair throat wound,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42950,Reconstruction of throat,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42953,Repair throat esophagus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42955,Surgical opening of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42960,Control throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42962,Control throat bleeding,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42970,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42972,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,42999,Throat surgery procedure,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43020,Incision of esophagus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43030,Throat muscle surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43100,Excision of esophagus lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43130,Removal of esophagus pouch,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43191,Esophagoscopy rigid trnso dx,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43192,Esophagoscp rig trnso inject,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43193,Esophagoscp rig trnso biopsy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43194,Esophagoscp rig trnso rem fb,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43196,Esophagoscp guide wire dilat,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43197,Esophagoscopy flex dx brush,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43198,Esophagosc flex trnsn biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43200,Esophagoscopy flexible brush,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43201,Esoph scope w/submucous inj,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43202,Esophagoscopy flex biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43204,Esoph scope w/sclerosis inj,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43205,Esophagus endoscopy/ligation,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43206,Esoph optical endomicroscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43211,Esophagoscop mucosal resect,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43213,Esophagoscopy retro balloon,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43214,Esophagosc dilate balloon 30,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43215,Esophagoscopy flex remove fb,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43216,Esophagoscopy lesion removal,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43217,Esophagoscopy snare les remv,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43220,Esophagoscopy balloon <30mm,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43226,Esoph endoscopy dilation,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43227,Esophagoscopy control bleed,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43229,Esophagoscopy lesion ablate,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43231,Esophagoscop ultrasound exam,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43232,Esophagoscopy w/us needle bx,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43233,Egd balloon dil esoph30 mm/>,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43235,Egd diagnostic brush wash,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43236,Uppr gi scope w/submuc inj,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43237,Endoscopic us exam esoph,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43238,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43239,Egd biopsy single/multiple,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43241,Egd tube/cath insertion,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43242,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43243,Egd injection varices,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43244,Egd varices ligation,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43245,Egd dilate stricture,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43246,Egd place gastrostomy tube,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43247,Egd remove foreign body,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43248,Egd guide wire insertion,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43249,Esoph egd dilation <30 mm,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43250,Egd cautery tumor polyp,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43251,Egd remove lesion snare,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43253,Egd us transmural injxn/mark,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43254,Egd endo mucosal resection,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43255,Egd control bleeding any,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43257,Egd w/thrml txmnt gerd,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43259,Egd us exam duodenum/jejunum,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43260,Ercp w/specimen collection,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43261,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43262,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43263,Ercp sphincter pressure meas,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43270,Egd lesion ablation,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43275,Ercp remove forgn body duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43276,Ercp stent exchange w/dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43277,Ercp ea duct/ampulla dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43279,Lap myotomy heller,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43280,Laparoscopy fundoplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43281,Lap paraesophag hern repair,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43282,Lap paraesoph her rpr w/mesh,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43283,Lap esoph lengthening,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43284,Laps esophgl sphnctr agmntj,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43285,Rmvl esophgl sphnctr dev,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43289,Laparoscope proc esoph,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43300,Repair of esophagus,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43305,Repair esophagus and fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43320,Fuse esophagus & stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43332,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43333,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43334,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43335,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43336,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43337,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43338,Esoph lengthening,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43401,Esophagus surgery for veins,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43410,Repair esophagus wound,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43420,Repair esophagus opening,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43450,Dilate esophagus 1/mult pass,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43453,Dilate esophagus,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43499,Esophagus surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43500,Surgical opening of stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43510,Surgical opening of stomach,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43520,Incision of pyloric muscle,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43610,Excision of stomach lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43644,Lap gastric bypass/roux-en-y,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43645,Lap gastr bypass incl smll i,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43647,Lap impl electrode antrum,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43648,Lap revise/remv eltrd antrum,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43651,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43652,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43653,Laparoscopy gastrostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43659,Laparoscope proc stom,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43752,Nasal/orogastric w/tube plmt,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43753,Tx gastro intub w/asp,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43754,Dx gastr intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43755,Dx gastr intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43756,Dx duod intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43757,Dx duod intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43760,Change gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43761,Reposition gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43762,Rplc gtube no revj trc,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43763,Rplc gtube revj gstrst trc,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43770,Lap place gastr adj device,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43771,Lap revise gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43772,Lap rmvl gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43773,Lap replace gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43774,Lap rmvl gastr adj all parts,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43775,Lap sleeve gastrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43830,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43831,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43832,Place gastrostomy tube,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43842,V-band gastroplasty,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43843,Gastroplasty w/o v-band,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43848,Revision gastroplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43860,Revise stomach-bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43870,Repair stomach opening,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43880,Repair stomach-bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43881,Impl/redo electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43882,Revise/remove electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43886,Revise gastric port open,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43887,Remove gastric port open,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43888,Change gastric port open,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,43999,Stomach surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44005,Freeing of bowel adhesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44015,Insert needle cath bowel,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44020,Explore small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44050,Reduce bowel obstruction,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44055,Correct malrotation of bowel,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44100,Biopsy of bowel,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44110,Excise intestine lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44111,Excision of bowel lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44125,Removal of small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44130,Bowel to bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44139,Mobilization of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44141,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44143,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44180,Lap enterolysis,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44186,Lap jejunostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44187,Lap ileo/jejuno-stomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44188,Lap colostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44204,Laparo partial colectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44206,Lap part colectomy w/stoma,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44207,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44208,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44213,Lap mobil splenic fl add-on,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44238,Laparoscope proc intestine,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44300,Open bowel to skin,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44312,Revision of ileostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44320,Colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44340,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44346,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44360,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44361,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44363,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44364,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44365,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44366,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44369,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44370,Small bowel endoscopy/stent,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44372,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44373,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44376,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44377,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44378,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44379,S bowel endoscope w/stent,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44380,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44381,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44382,Small bowel endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44384,Small bowel endoscopy,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44385,Endoscopy of bowel pouch,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44386,Endoscopy bowel pouch/biop,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44388,Colonoscopy thru stoma spx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44389,Colonoscopy with biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44390,Colonoscopy for foreign body,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44391,Colonoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44392,Colonoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44394,Colonoscopy w/snare,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44401,Colonoscopy with ablation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44402,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44403,Colonoscopy w/resection,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44404,Colonoscopy w/injection,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44405,Colonoscopy w/dilation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44406,Colonoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44407,Colonoscopy w/ndl aspir/bx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44408,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44500,Intro gastrointestinal tube,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44602,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44603,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44615,Intestinal stricturoplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44620,Repair bowel opening,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44640,Repair bowel-skin fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44650,Repair bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44799,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44800,Excision of bowel pouch,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44820,Excision of mesentery lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44850,Repair of mesentery,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44899,Bowel surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44900,Drain appendix abscess open,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44950,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44955,Appendectomy add-on,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44960,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44970,Laparoscopy appendectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,44979,Laparoscope proc app,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45000,Drainage of pelvic abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45005,Drainage of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45020,Drainage of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45100,Biopsy of rectum,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45108,Removal of anorectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45113,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45123,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45130,Excision of rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45136,Excise ileoanal reservior,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45150,Excision of rectal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45160,Excision of rectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45171,Exc rect tum transanal part,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45172,Exc rect tum transanal full,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45190,Destruction rectal tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45300,Proctosigmoidoscopy dx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45303,Proctosigmoidoscopy dilate,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45305,Proctosigmoidoscopy w/bx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45307,Proctosigmoidoscopy fb,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45308,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45309,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45315,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45317,Proctosigmoidoscopy bleed,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45320,Proctosigmoidoscopy ablate,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45321,Proctosigmoidoscopy volvul,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45327,Proctosigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45330,Diagnostic sigmoidoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45331,Sigmoidoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45332,Sigmoidoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45333,Sigmoidoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45334,Sigmoidoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45335,Sigmoidoscopy w/submuc inj,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45337,Sigmoidoscopy & decompress,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45338,Sigmoidoscopy w/tumr remove,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45340,Sig w/tndsc balloon dilation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45341,Sigmoidoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45342,Sigmoidoscopy w/us guide bx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45346,Sigmoidoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45347,Sigmoidoscopy w/plcmt stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45349,Sigmoidoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45350,Sgmdsc w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45378,Diagnostic colonoscopy,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45379,Colonoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45380,Colonoscopy and biopsy,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45381,Colonoscopy submucous njx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45382,Colonoscopy w/control bleed,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45384,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45385,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45386,Colonoscopy w/balloon dilat,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45388,Colonoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45389,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45390,Colonoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45391,Colonoscopy w/endoscope us,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45392,Colonoscopy w/endoscopic fnb,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45393,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45398,Colonoscopy w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45399,Unlisted procedure colon,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45400,Laparoscopic proc,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45402,Lap proctopexy w/sig resect,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45499,Laparoscope proc rectum,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45500,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45505,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45520,Treatment of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45541,Correct rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45560,Repair of rectocele,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45562,Exploration/repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45800,Repair rect/bladder fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45820,Repair rectourethral fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45900,Reduction of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45905,Dilation of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45910,Dilation of rectal narrowing,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45915,Remove rectal obstruction,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45990,Surg dx exam anorectal,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,45999,Rectum surgery procedure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46020,Placement of seton,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46030,Removal of rectal marker,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46040,Incision of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46045,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46050,Incision of anal abscess,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46060,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46070,Incision of anal septum,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46080,Incision of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46083,Incise external hemorrhoid,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46200,Removal of anal fissure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46220,Excise anal ext tag/papilla,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46221,Ligation of hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46230,Removal of anal tags,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46250,Remove ext hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46255,Remove int/ext hem 1 group,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46257,Remove in/ex hem grp & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46258,Remove in/ex hem grp w/fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46260,Remove in/ex hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46261,Remove in/ex hem grps & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46262,Remove in/ex hem grps w/fist,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46270,Remove anal fist subq,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46275,Remove anal fist inter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46280,Remove anal fist complex,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46285,Remove anal fist 2 stage,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46288,Repair anal fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46320,Removal of hemorrhoid clot,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46500,Injection into hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46505,Chemodenervation anal musc,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46600,Diagnostic anoscopy spx,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46601,Diagnostic anoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46604,Anoscopy and dilation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46606,Anoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46607,Diagnostic anoscopy & biopsy,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46608,Anoscopy remove for body,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46610,Anoscopy remove lesion,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46611,Anoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46612,Anoscopy remove lesions,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46614,Anoscopy control bleeding,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46615,Anoscopy,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46700,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46705,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46706,Repr of anal fistula w/glue,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46707,Repair anorectal fist w/plug,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46710,Repr per/vag pouch sngl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46712,Repr per/vag pouch dbl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46715,Rep perf anoper fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46716,Rep perf anoper/vestib fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46740,Construction of absent anus,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46750,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46751,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46753,Reconstruction of anus,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46754,Removal of suture from anus,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46760,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46761,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46762,Implant artificial sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46900,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46910,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46916,Cryosurgery anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46917,Laser surgery anal lesions,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46922,Excision of anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46924,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46930,Destroy internal hemorrhoids,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46940,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46942,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46945,Int hrhc lig 1 hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46946,Int hrhc lig 2+hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46947,Hemorrhoidopexy by stapling,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46948,Int hrhc tranal dartlzj 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,46999,Anus surgery procedure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47370,Laparo ablate liver tumor rf,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47371,Laparo ablate liver cryosurg,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47379,Laparoscope procedure liver,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47510,Insert catheter bile duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47511,Insert bile duct drain,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47525,Change bile duct catheter,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47530,Revise/reinsert bile tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47537,Removal biliary drg cath,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47560,Laparoscopy w/cholangio,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47561,Laparo w/cholangio/biopsy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47562,Laparoscopic cholecystectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47563,Laparo cholecystectomy/graph,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47564,Laparo cholecystectomy/explr,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47570,Laparo cholecystoenterostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47579,Laparoscope proc biliary,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,47630,Remove bile duct stone,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,48550,Donor pancreatectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49000,Exploration of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49002,Reopening of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49010,Exploration behind abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49203,Exc abd tum 5 cm or less,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49204,Exc abd tum over 5 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49205,Exc abd tum over 10 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49215,Excise sacral spine tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49220,Multiple surgery abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49250,Excision of umbilicus,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49255,Removal of omentum,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49320,Diag laparo separate proc,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49321,Laparoscopy biopsy,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49322,Laparoscopy aspiration,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49323,Laparo drain lymphocele,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49324,Lap insert tunnel ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49325,Lap revision perm ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49326,Lap w/omentopexy add-on,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49329,Laparo proc abdm/per/oment,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49402,Remove foreign body adbomen,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49425,Insert abdomen-venous drain,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49426,Revise abdomen-venous shunt,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49428,Ligation of shunt,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49429,Removal of shunt,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49440,Place gastrostomy tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49441,Place duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49442,Place cecostomy tube perc,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49446,Change g-tube to g-j perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49450,Replace g/c tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49451,Replace duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49452,Replace g-j tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49460,Fix g/colon tube w/device,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49491,Rpr hern preemie reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49492,Rpr ing hern premie blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49495,Rpr ing hernia baby reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49496,Rpr ing hernia baby blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49500,Rpr ing hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49501,Rpr ing hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49505,Prp i/hern init reduc >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49507,Prp i/hern init block >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49520,Rerepair ing hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49521,Rerepair ing hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49525,Repair ing hernia sliding,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49540,Repair lumbar hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49550,Rpr rem hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49553,Rpr fem hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49555,Rerepair fem hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49557,Rerepair fem hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49560,Rpr ventral hern init reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49561,Rpr ventral hern init block,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49565,Rerepair ventrl hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49566,Rerepair ventrl hern block,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49568,Hernia repair w/mesh,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49570,Rpr epigastric hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49572,Rpr epigastric hern blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49580,Rpr umbil hern reduc < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49582,Rpr umbil hern block < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49585,Rpr umbil hern reduc > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49587,Rpr umbil hern block > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49590,Repair spigelian hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49600,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49606,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49610,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49650,Lap ing hernia repair init,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49651,Lap ing hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49652,Lap vent/abd hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49653,Lap vent/abd hern proc comp,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49654,Lap inc hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49655,Lap inc hern repair comp,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49656,Lap inc hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49657,Lap inc hern recur comp,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49659,Laparo proc hernia repair,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49900,Repair of abdominal wall,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49904,Omental flap extra-abdom,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49905,Omental flap intra-abdom,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49906,Free omental flap microvasc,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,49999,Abdomen surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50389,Remove renal tube w/fluoro,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50390,Drainage of kidney lesion,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50391,Instll rx agnt into rnal tub,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50396,Measure kidney pressure,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50398,Change kidney tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50430,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50431,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50541,Laparo ablate renal cyst,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50542,Laparo ablate renal mass,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50543,Laparo partial nephrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50544,Laparoscopy pyeloplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50549,Laparoscope proc renal,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50945,Laparoscopy ureterolithotomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50947,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50948,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,50949,Laparoscope proc ureter,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51100,Drain bladder by needle,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51500,Removal of bladder cyst,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51705,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51710,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51715,Endoscopic injection/implant,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51720,Treatment of bladder lesion,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51725,Simple cystometrogram,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51726,Complex cystometrogram,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51727,Cystometrogram w/up,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51728,Cystometrogram w/vp,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51729,Cystometrogram w/vp&up,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51741,Electro-uroflowmetry first,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51784,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51785,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51792,Urinary reflex study,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51990,Laparo urethral suspension,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51992,Laparo sling operation,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,51999,Laparoscope proc bla,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52010,Cystoscopy & duct catheter,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52270,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52275,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52276,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52277,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52282,Cystoscopy implant stent,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52283,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52285,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52400,Cystouretero w/congen repr,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52402,Cystourethro cut ejacul duct,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52442,Cystourethro w/addl implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52601,Prostatectomy (turp),Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52630,Remove prostate regrowth,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52647,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52648,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,52649,Prostate laser enucleation,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53000,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53010,Incision of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53020,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53025,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53040,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53060,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53080,Drainage of urinary leakage,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53085,Drainage of urinary leakage,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53200,Biopsy of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53210,Removal of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53215,Removal of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53220,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53230,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53235,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53240,Surgery for urethra pouch,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53250,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53260,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53265,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53270,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53275,Repair of urethra defect,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53400,Revise urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53405,Revise urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53410,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53415,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53420,Reconstruct urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53425,Reconstruct urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53430,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53431,Reconstruct urethra/bladder,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53440,Male sling procedure,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53442,Remove/revise male sling,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53444,Insert tandem cuff,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53446,Remove uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53448,Remov/replc ur sphinctr comp,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53449,Repair uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53450,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53460,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53500,Urethrlys transvag w/ scope,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53502,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53505,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53510,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53515,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53520,Repair of urethra defect,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53605,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53620,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53621,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53665,Dilation of urethra,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53855,Insert prost urethral stent,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,53860,Transurethral rf treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54000,Slitting of prepuce,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54001,Slitting of prepuce,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54015,Drain penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54050,Destruction penis lesion(s),Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54055,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54056,Cryosurgery penis lesion(s),Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54057,Laser surg penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54060,Excision of penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54065,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54100,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54105,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54110,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54115,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54150,Circumcision w/regionl block,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54160,Circumcision neonate,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54161,Circum 28 days or older,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54162,Lysis penil circumic lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54163,Repair of circumcision,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54164,Frenulotomy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54230,Prepare penis study,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54231,Dynamic cavernosometry,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54300,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54304,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54340,Secondary urethral surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54360,Penis plastic surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54380,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54385,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54400,Insert semi-rigid prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54401,Insert self-contd prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54405,Insert multi-comp penis pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54406,Remove muti-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54408,Repair multi-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54410,Remove/replace penis prosth,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54411,Remov/replc penis pros comp,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54415,Remove self-contd penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54416,Remv/repl penis contain pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54417,Remv/replc penis pros compl,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54420,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54430,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54435,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54440,Repair of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54450,Preputial stretching,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54500,Biopsy of testis,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54505,Biopsy of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54512,Excise lesion testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54520,Removal of testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54522,Orchiectomy partial,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54530,Removal of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54535,Extensive testis surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54550,Exploration for testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54560,Exploration for testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54600,Reduce testis torsion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54620,Suspension of testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54640,Orchiopexy ingun/scrot appr,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54650,Orchiopexy (fowler-stephens),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54660,Revision of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54670,Repair testis injury,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54680,Relocation of testis(es),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54690,Laparoscopy orchiectomy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54692,Laparoscopy orchiopexy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54699,Laparoscope proc testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54700,Drainage of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54800,Biopsy of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54830,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54840,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54860,Removal of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54861,Removal of epididymis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54865,Explore epididymis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54900,Fusion of spermatic ducts,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,54901,Fusion of spermatic ducts,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55040,Removal of hydrocele,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55041,Removal of hydroceles,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55060,Repair of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55100,Drainage of scrotum abscess,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55110,Explore scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55120,Removal of scrotum lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55150,Removal of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55175,Revision of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55180,Revision of scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55200,Incision of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55250,Removal of sperm duct(s),Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55400,Repair of sperm duct,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55450,Ligation of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55500,Removal of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55520,Removal of sperm cord lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55530,Revise spermatic cord veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55535,Revise spermatic cord veins,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55540,Revise hernia & sperm veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55550,Laparo ligate spermatic vein,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55559,Laparo proc spermatic cord,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55600,Incise sperm duct pouch,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55605,Incise sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55650,Remove sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55680,Remove sperm pouch lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55801,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55810,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55815,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55821,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55831,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55840,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55842,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55845,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55860,Surgical exposure prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55866,Laparo radical prostatectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55870,Electroejaculation,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55873,Cryoablate prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55874,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55880,Abltj mal prst8 tiss hifu,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,55899,Genital surgery procedure,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,56405,I & d of vulva/perineum,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,56420,Drainage of gland abscess,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,56820,Exam of vulva w/scope,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57150,Treat vagina infection,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57160,Insert pessary/other device,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57170,Fitting of diaphragm/cap,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57220,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57230,Repair of urethral lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57240,Anterior colporrhaphy,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57250,Repair rectum & vagina,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57260,Cmbn ant pst colprhy,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57267,Insert mesh/pelvic flr addon,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57268,Repair of bowel bulge,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57270,Repair of bowel pouch,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57287,Revise/remove sling repair,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57288,Repair bladder defect,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57289,Repair bladder & vagina,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,57410,Pelvic examination,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,58300,Insert intrauterine device,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,58301,Remove intrauterine device,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,58321,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,58322,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,58323,Sperm washing,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,58970,Retrieval of oocyte,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,58974,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,58976,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59020,Fetal contract stress test,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59025,Fetal non-stress test,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59030,Fetal scalp blood sample,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59050,Fetal monitor w/report,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59072,Umbilical cord occlud w/us,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59074,Fetal fluid drainage w/us,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59076,Fetal shunt placement w/us,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59400,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59409,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59410,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59610,Vbac delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59612,Vbac delivery only,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59614,Vbac care after delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59812,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59820,Care of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59821,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59830,Treat uterus infection,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59840,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59841,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59850,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59851,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59852,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59855,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59856,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59857,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59866,Abortion (mpr),Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,59897,Fetal invas px w/us,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,60000,Drain thyroid/tongue cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,60100,Biopsy of thyroid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,60300,Aspir/inj thyroid cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,60650,Laparoscopy adrenalectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,60659,Laparo proc endocrine,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,60699,Endocrine surgery procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61000,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61001,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61020,Remove brain cavity fluid,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61026,Injection into brain canal,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61070,Brain canal shunt procedure,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61215,Insert brain-fluid device,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61623,Endovasc tempory vessel occl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61624,Transcath occlusion cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61626,Transcath occlusion non-cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61630,Intracranial angioplasty,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61635,Intracran angioplsty w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61640,Dilate ic vasospasm init,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61641,Dilat ic vspsm ea vsl sm ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61642,Dilat ic vspsm ea diff ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61645,Perq art m-thrombect &/nfs,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61651,Evasc prlng admn rx agnt add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61720,Incise skull/brain surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61770,Incise skull for treatment,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61790,Treat trigeminal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61791,Treat trigeminal tract,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61796,Srs cranial lesion simple,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61797,Srs cran les simple addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61798,Srs cranial lesion complex,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61799,Srs cran les complex addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61800,Apply srs headframe add-on,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61850,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61880,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61885,Insrt/redo neurostim 1 array,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61886,Implant neurostim arrays,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,61888,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62000,Treat skull fracture,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62194,Replace/irrigate catheter,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62225,Replace/irrigate catheter,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62230,Replace/revise brain shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62252,Csf shunt reprogram,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62292,Njx chemonucleolysis lmbr,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62302,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62303,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62304,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62305,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62310,Inject spine cerv/thoracic,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62311,Inject spine lumbar/sacral,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62318,Inject spine w/cath crv/thrc,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62319,Inject spine w/cath lmb/scrl,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62350,Implant spinal canal cath,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62355,Remove spinal canal catheter,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62360,Insert spine infusion device,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62361,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62362,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62365,Remove spine infusion device,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62367,Analyze spine infus pump,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62368,Analyze sp inf pump w/reprog,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62369,Anal sp inf pmp w/reprg&fill,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,62370,Anl sp inf pmp w/mdreprg&fil,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63600,Remove spinal cord lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63610,Stimulation of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63615,Remove lesion of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63620,Srs spinal lesion,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63621,Srs spinal lesion addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63650,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63661,Remove spine eltrd perq aray,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63662,Remove spine eltrd plate,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63663,Revise spine eltrd perq aray,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63664,Revise spine eltrd plate,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63685,Insrt/redo spine n generator,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63688,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63707,Repair spinal fluid leakage,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63741,Install spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63744,Revision of spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,63746,Removal of spinal shunt,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64400,Njx aa&/strd trigeminal nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64402,N block inj facial,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64405,Njx aa&/strd gr ocpl nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64408,Njx aa&/strd vagus nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64410,N block inj phrenic,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64412,N block inj spinal accessor,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64413,N block inj cervical plexus,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64415,Njx aa&/strd brach plexus,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64416,Njx aa&/strd brach plex nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64417,Njx aa&/strd axillary nrv,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64418,Njx aa&/strd sprscap nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64420,Njx aa&/strd ntrcost nrv 1,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64421,Njx aa&/strd ntrcost nrv ea,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64425,Njx aa&/strd ii ih nerves,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64430,Njx aa&/strd pudendal nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64435,Njx aa&/strd paracrv nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64445,Njx aa&/strd sciatic nerve,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64446,Njx aa&/strd sciatic nrv nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64447,Njx aa&/strd femoral nerve,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64448,Njx aa&/strd fem nerve nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64449,Njx aa&/strd lmbr plex nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64450,Njx aa&/strd other pn/branch,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64454,Njx aa&/strd gnclr nrv brnch,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64455,Njx aa&/strd pltr com dg nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64486,Tap block unil by injection,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64487,Tap block uni by infusion,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64488,Tap block bi injection,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64489,Tap block bi by infusion,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64505,N block spenopalatine gangl,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64508,N block carotid sinus s/p,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64510,N block stellate ganglion,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64517,N block inj hypogas plxs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64530,N block inj celiac pelus,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64550,Appl surface neurostimulator,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64553,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64555,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64561,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64565,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64566,Neuroeltrd stim post tibial,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64568,Inc for vagus n elect impl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64569,Revise/repl vagus n eltrd,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64570,Remove vagus n eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64575,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64580,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64581,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64585,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64590,Insrt/redo pn/gastr stimul,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64595,Revise/rmv pn/gastr stimul,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64600,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64605,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64610,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64611,Chemodenerv saliv glands,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64612,Destroy nerve face muscle,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64615,Chemodenerv musc migraine,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64616,Chemodenerv musc neck dyston,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64617,Chemodener muscle larynx emg,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64620,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64624,Dstrj nulyt agt gnclr nrv,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64625,Rf abltj nrv nrvtg si jt,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64630,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64632,N block inj common digit,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64640,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64642,Chemodenerv 1 extremity 1-4,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64643,Chemodenerv 1 extrem 1-4 ea,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64644,Chemodenerv 1 extrem 5/> mus,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64645,Chemodenerv 1 extrem 5/> ea,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64646,Chemodenerv trunk musc 1-5,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64647,Chemodenerv trunk musc 6/>,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64650,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64653,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64680,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64681,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64702,Revise finger/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64704,Revise hand/foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64708,Revise arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64712,Revision of sciatic nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64713,Revision of arm nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64714,Revise low back nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64716,Revision of cranial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64718,Revise ulnar nerve at elbow,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64719,Revise ulnar nerve at wrist,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64721,Carpal tunnel surgery,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64722,Relieve pressure on nerve(s),Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64726,Release foot/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64727,Internal nerve revision,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64732,Incision of brow nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64734,Incision of cheek nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64736,Incision of chin nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64738,Incision of jaw nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64740,Incision of tongue nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64742,Incision of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64744,Incise nerve back of head,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64746,Incise diaphragm nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64763,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64766,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64771,Sever cranial nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64772,Incision of spinal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64774,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64776,Remove digit nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64778,Digit nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64782,Remove limb nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64783,Limb nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64784,Remove nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64786,Remove sciatic nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64787,Implant nerve end,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64788,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64790,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64792,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64795,Biopsy of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64802,Sympathectomy cervical,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64804,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64818,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64820,Sympathectomy digital artery,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64821,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64822,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64823,Sympathectomy supfc palmar,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64831,Repair of digit nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64832,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64834,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64835,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64836,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64837,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64840,Repair of leg nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64856,Repair/transpose nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64857,Repair arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64858,Repair sciatic nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64859,Nerve surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64861,Repair of arm nerves,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64862,Repair of low back nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64864,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64865,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64866,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64868,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64872,Subsequent repair of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64874,Repair & revise nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64876,Repair nerve/shorten bone,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64885,Nerve graft head/neck 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64886,Nerve graft head/neck >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64890,Nerve graft hand/foot 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64891,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64892,Nerve graft arm/leg <4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64893,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64895,Nerve graft hand/foot 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64896,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64897,Nerve graft arm/leg 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64898,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64901,Nerve graft add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64902,Nerve graft add-on,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64905,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64907,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64910,Nerve repair w/allograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64911,Neurorraphy w/vein autograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64912,Nrv rpr w/nrv algrft 1st,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64913,Nrv rpr w/nrv algrft ea addl,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,64999,Nervous system surgery,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65091,Revise eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65093,Revise eye with implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65101,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65103,Remove eye/insert implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65105,Remove eye/attach implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65110,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65112,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65114,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65125,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65130,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65135,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65140,Attach ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65150,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65155,Reinsert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65175,Removal of ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65205,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65210,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65220,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65222,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65235,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65260,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65265,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65270,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65272,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65275,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65280,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65285,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65286,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65290,Repair of eye socket wound,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65400,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65410,Biopsy of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65420,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65426,Removal of eye lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65430,Corneal smear,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65435,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65436,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65450,Treatment of corneal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65600,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65710,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65730,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65750,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65755,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65756,Corneal trnspl endothelial,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65757,Prep corneal endo allograft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65760,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65765,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65767,Corneal tissue transplant,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65770,Revise cornea with implant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65771,Radial keratotomy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65772,Correction of astigmatism,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65775,Correction of astigmatism,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65778,Cover eye w/membrane,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65779,Cover eye w/membrane suture,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65780,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65781,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65782,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65785,Impltj ntrstrml crnl rng seg,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65800,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65810,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65815,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65820,Relieve inner eye pressure,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65850,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65855,Trabeculoplasty laser surg,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65860,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65865,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65870,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65875,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65880,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65900,Remove eye lesion,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65920,Remove implant of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,65930,Remove blood clot from eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66020,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66030,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66130,Remove eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66150,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66155,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66160,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66170,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66172,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66174,Translum dil eye canal,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66175,Trnslum dil eye canal w/stnt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66179,Aqueous shunt eye w/o graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66180,Aqueous shunt eye w/graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66183,Insert ant drainage device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66184,Revision of aqueous shunt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66185,Revise aqueous shunt eye,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66220,Repair eye lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66225,Repair/graft eye lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66250,Follow-up surgery of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66500,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66505,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66600,Remove iris and lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66605,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66625,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66630,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66635,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66680,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66682,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66700,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66710,Ciliary transsleral therapy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66711,Ecp ciliary body destruction,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66720,Destruction ciliary body,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66740,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66761,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66762,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66770,Removal of inner eye lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66820,Incision secondary cataract,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66821,After cataract laser surgery,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66825,Reposition intraocular lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66830,Removal of lens lesion,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66840,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66850,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66852,Removal of lens material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66920,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66930,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66940,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66983,Cataract surg w/iol 1 stage,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66984,Xcapsl ctrc rmvl w/o ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66985,Insert lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66986,Exchange lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66988,Xcapsl ctrc rmvl w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,66999,Eye surgery procedure,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67005,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67010,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67015,Release of eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67025,Replace eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67027,Implant eye drug system,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67028,Injection eye drug,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67030,Incise inner eye strands,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67031,Laser surgery eye strands,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67036,Removal of inner eye fluid,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67039,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67040,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67041,Vit for macular pucker,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67042,Vit for macular hole,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67043,Vit for membrane dissect,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67101,Repair detached retina crtx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67105,Repair detached retina pc,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67107,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67108,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67110,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67112,Rerepair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67113,Repair retinal detach cplx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67115,Release encircling material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67120,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67121,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67141,Treatment of retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67145,Treatment of retina,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67208,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67210,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67218,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67220,Treatment of choroid lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67221,Ocular photodynamic ther,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67225,Eye photodynamic ther add-on,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67227,Dstrj extensive retinopathy,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67228,Treatment x10sv retinopathy,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67229,Tr retinal les preterm inf,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67250,Reinforce eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67255,Reinforce/graft eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67299,Eye surgery procedure,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67311,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67312,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67314,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67316,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67318,Revise eye muscle(s),Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67320,Revise eye muscle(s) add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67331,Eye surgery follow-up add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67332,Rerevise eye muscles add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67334,Revise eye muscle w/suture,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67335,Eye suture during surgery,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67340,Revise eye muscle add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67343,Release eye tissue,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67345,Destroy nerve of eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67346,Biopsy eye muscle,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67399,Unlisted px extraocular musc,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67400,Explore/biopsy eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67405,Explore/drain eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67412,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67413,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67414,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67415,Aspiration orbital contents,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67445,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67500,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67505,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67515,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67550,Insert eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67560,Revise eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67570,Decompress optic nerve,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67599,Orbit surgery procedure,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67700,Drainage of eyelid abscess,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67710,Incision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67715,Incision of eyelid fold,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67800,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67801,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67805,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67808,Remove eyelid lesion(s),Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67810,Biopsy eyelid & lid margin,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67820,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67825,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67830,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67835,Revise eyelashes,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67840,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67850,Treat eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67875,Closure of eyelid by suture,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67880,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67882,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67900,Repair brow defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67901,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67902,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67903,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67904,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67906,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67908,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67909,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67911,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67912,Correction eyelid w/implant,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67914,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67915,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67916,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67917,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67921,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67922,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67923,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67924,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67930,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67935,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67938,Remove eyelid foreign body,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67950,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67961,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67966,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67971,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67973,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67974,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67975,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,67999,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68020,Incise/drain eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68040,Treatment of eyelid lesions,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68100,Biopsy of eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68110,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68115,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68130,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68135,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68200,Treat eyelid by injection,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68320,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68325,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68326,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68328,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68330,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68335,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68340,Separate eyelid adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68360,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68362,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68371,Harvest eye tissue alograft,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68399,Eyelid lining surgery,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68400,Incise/drain tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68420,Incise/drain tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68440,Incise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68500,Removal of tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68505,Partial removal tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68510,Biopsy of tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68520,Removal of tear sac,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68525,Biopsy of tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68530,Clearance of tear duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68540,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68550,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68700,Repair tear ducts,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68705,Revise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68720,Create tear sac drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68745,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68750,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68760,Close tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68761,Close tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68770,Close tear system fistula,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68801,Dilate tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68810,Probe nasolacrimal duct,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68811,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68815,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68816,Probe nl duct w/balloon,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68840,Explore/irrigate tear ducts,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,68899,Tear duct system surgery,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69005,Drain external ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69100,Biopsy of external ear,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69105,Biopsy of external ear canal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69110,Remove external ear partial,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69120,Removal of external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69140,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69145,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69150,Extensive ear canal surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69155,Extensive ear/neck surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69205,Clear outer ear canal,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69222,Clean out mastoid cavity,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69300,Revise external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69310,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69320,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69399,Outer ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69421,Incision of eardrum,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69424,Remove ventilating tube,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69433,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69436,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69440,Exploration of middle ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69450,Eardrum revision,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69501,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69502,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69505,Remove mastoid structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69511,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69530,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69540,Remove ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69550,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69552,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69601,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69602,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69603,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69604,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69605,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69610,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69620,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69631,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69632,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69633,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69635,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69636,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69637,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69641,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69642,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69643,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69644,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69645,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69646,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69650,Release middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69660,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69661,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69662,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69666,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69667,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69670,Remove mastoid air cells,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69676,Remove middle ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69700,Close mastoid fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69705,Nps surg dilat eust tube uni,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69706,Nps surg dilat eust tube bi,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69710,Implant/replace hearing aid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69711,Remove/repair hearing aid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69714,Implant temple bone w/stimul,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69715,Temple bne implnt w/stimulat,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69717,Temple bone implant revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69718,Revise temple bone implant,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69720,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69725,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69740,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69745,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69799,Middle ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69801,Incise inner ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69805,Explore inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69806,Explore inner ear,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69820,Establish inner ear window,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69840,Revise inner ear window,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69905,Remove inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69910,Remove inner ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69915,Incise inner ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69930,Implant cochlear device,Otolaryngology Surgery,Per Unit,"$15,529.51 ",OP,"$15,529.51 ","$15,529.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69949,Inner ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69955,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,69960,Release inner ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70010,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70015,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70030,X-ray eye for foreign body,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70100,X-ray exam of jaw <4views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70110,X-ray exam of jaw 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70120,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70130,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70134,X-ray exam of middle ear,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70140,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70150,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70160,X-ray exam of nasal bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70190,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70200,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70210,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70220,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70240,X-ray exam pituitary saddle,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70250,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70260,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70300,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70310,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70320,Full mouth x-ray of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70328,X-ray exam of jaw joint,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70330,X-ray exam of jaw joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70336,Magnetic image jaw joint,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70350,X-ray head for orthodontia,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70355,Panoramic x-ray of jaws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70360,X-ray exam of neck,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70370,Throat x-ray & fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70373,Contrast x-ray of larynx,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70380,X-ray exam of salivary gland,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70450,Ct head/brain w/o dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70460,Ct head/brain w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70470,Ct head/brain w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70480,Ct orbit/ear/fossa w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70481,Ct orbit/ear/fossa w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70486,Ct maxillofacial w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70487,Ct maxillofacial w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70488,Ct maxillofacial w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70490,Ct soft tissue neck w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70491,Ct soft tissue neck w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70492,Ct sft tsue nck w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70496,Ct angiography head,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70498,Ct angiography neck,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70540,Mri orbit/face/neck w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70542,Mri orbit/face/neck w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70543,Mri orbt/fac/nck w/o &w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70544,Mr angiography head w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70545,Mr angiography head w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70546,Mr angiograph head w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70547,Mr angiography neck w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70548,Mr angiography neck w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70549,Mr angiograph neck w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70551,Mri brain stem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70552,Mri brain stem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70553,Mri brain stem w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70554,Fmri brain by tech,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70555,Fmri brain by phys/psych,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70557,Mri brain w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70558,Mri brain w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,70559,Mri brain w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71010,Chest x-ray 1 view frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71015,Chest x-ray stereo frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71020,Chest x-ray 2vw frontal&latl,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71021,Chest x-ray frnt lat lordotc,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71022,Chest x-ray frnt lat oblique,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71023,Chest x-ray and fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71030,Chest x-ray 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71034,Chest x-ray&fluoro 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71035,Chest x-ray special views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71045,X-ray exam chest 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71046,X-ray exam chest 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71047,X-ray exam chest 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71048,X-ray exam chest 4+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71100,X-ray exam ribs uni 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71101,X-ray exam unilat ribs/chest,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71110,X-ray exam ribs bil 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71111,X-ray exam ribs/chest4/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71120,X-ray exam breastbone 2/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71130,X-ray strenoclavic jt 3/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71250,Ct thorax dx c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71260,Ct thorax dx c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71270,Ct thorax dx c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71271,Ct thorax lung cancer scr c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71275,Ct angiography chest,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71550,Mri chest w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71551,Mri chest w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71552,Mri chest w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,71555,Mri angio chest w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72010,X-ray exam spine ap&lat,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72020,X-ray exam of spine 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72040,X-ray exam neck spine 2-3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72050,X-ray exam neck spine 4/5vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72052,X-ray exam neck spine 6/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72069,X-ray exam trunk spine stand,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72070,X-ray exam thorac spine 2vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72072,X-ray exam thorac spine 3vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72074,X-ray exam thorac spine4/>vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72080,X-ray exam thoracolmb 2/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72081,X-ray exam entire spi 1 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72082,X-ray exam entire spi 2/3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72083,X-ray exam entire spi 4/5 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72084,X-ray exam entire spi 6/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72090,X-ray exam scloiosis erect,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72100,X-ray exam l-s spine 2/3 vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72110,X-ray exam l-2 spine 4/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72114,X-ray exam l-s spine bending,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72120,X-ray bend only l-s spine,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72125,Ct neck spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72126,Ct neck spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72127,Ct neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72128,Ct chest spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72129,Ct chest spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72130,Ct chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72131,Ct lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72132,Ct lumbar spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72133,Ct lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72141,Mri neck spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72142,Mri neck spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72146,Mri chest spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72147,Mri chest spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72148,Mri lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72149,Mri lumbar spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72156,Mri neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72157,Mri chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72158,Mri lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72159,Mr angio spine w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72170,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72190,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72191,Ct angiograph pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72192,Ct pelvis w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72193,Ct pelvis w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72194,Ct pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72195,Mri pelvis w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72196,Mri pelvis w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72197,Mri pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72198,Mr angio pelvis w/o & w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72200,X-ray exam si joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72202,X-ray exam si joints 3/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72220,X-ray exam sacrum tailbone,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72240,Myelography neck spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72255,Myelography thoracic spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72265,Myelography l-s spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72270,Myelogphy 2/> spine regions,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72275,Epidurography,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72285,Discography cerv/thor spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,72295,X-ray of lower spine disk,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73000,X-ray exam of collar bone,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73010,X-ray exam of shoulder blade,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73020,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73030,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73050,X-ray exam of shoulders,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73060,X-ray exam of humerus,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73070,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73080,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73090,X-ray exam of forearm,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73092,X-ray exam of arm infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73100,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73110,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73120,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73130,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73140,X-ray exam of finger(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73200,Ct upper extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73201,Ct upper extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73202,Ct uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73206,Ct angio upr extrm w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73218,Mri upper extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73219,Mri upper extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73220,Mri uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73221,Mri joint upr extrem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73222,Mri joint upr extrem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73223,Mri joint upr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73225,Mr angio upr extr w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73500,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73501,X-ray exam hip uni 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73502,X-ray exam hip uni 2-3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73503,X-ray exam hip uni 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73510,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73520,X-ray exam of hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73521,X-ray exam hips bi 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73522,X-ray exam hips bi 3-4 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73523,X-ray exam hips bi 5/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73530,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73540,X-ray exam of pelvis & hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73550,X-ray exam of thigh,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73551,X-ray exam of femur 1,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73552,X-ray exam of femur 2/>,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73560,X-ray exam of knee 1 or 2,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73562,X-ray exam of knee 3,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73564,X-ray exam knee 4 or more,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73565,X-ray exam of knees,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73590,X-ray exam of lower leg,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73592,X-ray exam of leg infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73600,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73610,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73620,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73630,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73650,X-ray exam of heel,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73660,X-ray exam of toe(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73700,Ct lower extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73701,Ct lower extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73702,Ct lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73706,Ct angio lwr extr w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73718,Mri lower extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73719,Mri lower extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73720,Mri lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73721,Mri jnt of lwr extre w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73722,Mri joint of lwr extr w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73723,Mri joint lwr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,73725,Mr ang lwr ext w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74000,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74010,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74018,X-ray exam abdomen 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74019,X-ray exam abdomen 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74020,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74021,X-ray exam abdomen 3+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74022,X-ray exam complete abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74150,Ct abdomen w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74160,Ct abdomen w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74170,Ct abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74174,Ct angio abd&pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74175,Ct angio abdom w/o & w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74176,Ct abd & pelvis w/o contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74177,Ct abd & pelv w/contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74178,Ct abd & pelv 1/> regns,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74181,Mri abdomen w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74182,Mri abdomen w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74183,Mri abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74185,Mri angio abdom w orw/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74210,X-ray xm phrnx&/crv esoph c+,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74220,X-ray xm esophagus 1cntrst,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74235,Remove esophagus obstruction,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74261,Ct colonography dx,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74262,Ct colonography dx w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74263,Ct colonography screening,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74300,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74301,X-rays at surgery add-on,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74305,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74320,Contrast x-ray of bile ducts,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74327,X-ray bile stone removal,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74328,X-ray bile duct endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74329,X-ray for pancreas endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74330,X-ray bile/panc endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74340,X-ray guide for gi tube,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74355,X-ray guide intestinal tube,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74360,X-ray guide gi dilation,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74363,X-ray bile duct dilation,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74475,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74480,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74485,Dilation urtr/urt rs&i,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74710,X-ray measurement of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74712,Mri fetal sngl/1st gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74713,Mri fetal ea addl gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,74742,X-ray fallopian tube,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75557,Cardiac mri for morph,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75559,Cardiac mri w/stress img,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75561,Cardiac mri for morph w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75563,Card mri w/stress img & dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75565,Card mri veloc flow mapping,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75571,Ct hrt w/o dye w/ca test,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75572,Ct hrt w/3d image,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75573,Ct hrt w/3d image congen,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75574,Ct angio hrt w/3d image,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75605,Contrast exam thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75635,Ct angio abdominal arteries,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75705,Artery x-rays spine,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75726,Artery x-rays abdomen,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75736,Artery x-rays pelvis,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75774,Artery x-ray each vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75791,Av dialysis shunt imaging,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75842,Vein x-ray adrenal glands,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75893,Venous sampling by catheter,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75894,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75896,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75901,Remove cva device obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75902,Remove cva lumen obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75945,Intravascular us,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75946,Intravascular us add-on,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75952,Endovasc repair abdom aorta,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75953,Abdom aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75954,Iliac aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75956,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75957,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75958,Xray place prox ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75959,Xray place dist ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75962,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75964,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75966,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75968,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75970,Vascular biopsy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75980,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75982,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75984,Xray control catheter change,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,75989,Abscess drainage under x-ray,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76010,X-ray nose to rectum,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76100,X-ray exam of body section,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76101,Complex body section x-ray,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76102,Complex body section x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76120,Cine/video x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76125,Cine/video x-rays add-on,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76145,Med physic dos eval rad exps,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76380,Cat scan follow-up study,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76390,Mr spectroscopy,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76391,Mr elastography,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76496,Fluoroscopic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76497,Ct procedure,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76498,Mri procedure,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76499,Radiographic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76506,Echo exam of head,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76510,Oph us dx b-scan&quan a-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76511,Oph us dx quan a-scan only,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76512,Oph us dx b-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76513,Oph us dx ant sgm us uni/bi,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76514,Echo exam of eye thickness,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76516,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76519,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76529,Echo exam of eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76536,Us exam of head and neck,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76604,Us exam chest,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76641,Ultrasound breast complete,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76642,Ultrasound breast limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76700,Us exam abdom complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76705,Echo exam of abdomen,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76706,Us abdl aorta screen aaa,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76770,Us exam abdo back wall comp,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76775,Us exam abdo back wall lim,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76776,Us exam k transpl w/doppler,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76800,Us exam spinal canal,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76801,Ob us < 14 wks single fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76802,Ob us < 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76805,Ob us >= 14 wks sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76810,Ob us >= 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76811,Ob us detailed sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76812,Ob us detailed addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76813,Ob us nuchal meas 1 gest,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76814,Ob us nuchal meas add-on,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76815,Ob us limited fetus(s),Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76816,Ob us follow-up per fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76817,Transvaginal us obstetric,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76818,Fetal biophys profile w/nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76819,Fetal biophys profil w/o nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76820,Umbilical artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76821,Middle cerebral artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76825,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76826,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76827,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76828,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76830,Transvaginal us non-ob,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76831,Echo exam uterus,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76856,Us exam pelvic complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76857,Us exam pelvic limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76870,Us exam scrotum,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76872,Us transrectal,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76873,Echograp trans r pros study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76881,Us compl joint r-t w/img,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76882,Us lmtd jt/nonvasc xtr strux,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76885,Us exam infant hips dynamic,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76886,Us exam infant hips static,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76930,Echo guide cardiocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76932,Echo guide for heart biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76936,Echo guide for artery repair,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76937,Us guide vascular access,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76940,Us guide tissue ablation,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76941,Echo guide for transfusion,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76942,Echo guide for biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76945,Echo guide villus sampling,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76946,Echo guide for amniocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76948,Echo guide ova aspiration,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76965,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76970,Ultrasound exam follow-up,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76975,Gi endoscopic ultrasound,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76977,Us bone density measure,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76978,Us trgt dyn mbubb 1st les,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76979,Us trgt dyn mbubb ea addl,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76981,Use parenchyma,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76982,Use 1st target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76983,Use ea addl target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76998,Us guide intraop,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,76999,Echo examination procedure,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77001,Fluoroguide for vein device,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77002,Needle localization by xray,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77003,Fluoroguide for spine inject,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77011,Ct scan for localization,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77012,Ct scan for needle biopsy,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77013,Ct guide for tissue ablation,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77014,Ct scan for therapy guide,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77021,Mri guidance ndl plmt rs&i,Interventional Radiology,Per Unit,$108.13 ,OP,$108.13 ,$108.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77022,Mri gdn parnchyma tiss abltj,Interventional Radiology,Per Unit,$108.13 ,OP,$108.13 ,$108.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77046,Mri breast c- unilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77047,Mri breast c- bilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77048,Mri breast c-+ w/cad uni,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77049,Mri breast c-+ w/cad bi,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77055,Mammogram one breast,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77056,Mammogram both breasts,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77057,Mammogram screening,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77058,Mri one breast,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77059,Mri both breasts,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77061,Breast tomosynthesis uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77062,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77063,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77065,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77066,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77067,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77072,X-rays for bone age,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77073,X-rays bone length studies,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77074,X-rays bone survey limited,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77076,X-rays bone survey infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77077,Joint survey single view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77078,Ct bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77080,Dxa bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77081,Dxa bone density/peripheral,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77084,Magnetic image bone marrow,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77085,Dxa bone density study,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77086,Fracture assessment via dxa,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77261,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77262,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77263,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77280,Set radiation therapy field,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77285,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77290,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77293,Respirator motion mgmt simul,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77295,3-d radiotherapy plan,Therapeutic Radiology,Per Unit,$68.45 ,OP,$68.45 ,$68.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77299,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77300,Radiation therapy dose plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77301,Radiotherapy dose plan imrt,Therapeutic Radiology,Per Unit,$68.45 ,OP,$68.45 ,$68.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77306,Telethx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77307,Telethx isodose plan cplx,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77316,Brachytx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77317,Brachytx isodose intermed,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77318,Brachytx isodose complex,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77321,Special teletx port plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77331,Special radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77332,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77333,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77334,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77336,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77338,Design mlc device for imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77370,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77371,Srs multisource,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77372,Srs linear based,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77373,Sbrt delivery,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77385,Ntsty modul rad tx dlvr smpl,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77386,Ntsty modul rad tx dlvr cplx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77387,Guidance for radj tx dlvr,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77399,External radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77401,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77402,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77407,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77412,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77417,Radiology port images(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77422,Neutron beam tx simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77423,Neutron beam tx complex,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77424,Io rad tx delivery by x-ray,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77425,Io rad tx deliver by elctrns,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77427,Radiation tx management x5,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77431,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77432,Stereotactic radiation trmt,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77435,Sbrt management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77469,Io radiation tx management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77470,Special radiation treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77499,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77520,Proton trmt simple w/o comp,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77522,Proton trmt simple w/comp,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77523,Proton trmt intermediate,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77525,Proton treatment complex,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77600,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77605,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77610,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77615,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77620,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77750,Infuse radioactive materials,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77761,Apply intrcav radiat simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77762,Apply intrcav radiat interm,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77763,Apply intrcav radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77767,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77768,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77770,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77771,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77772,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77776,Apply interstit radiat simpl,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77777,Apply interstit radiat inter,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77778,Apply interstit radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77785,Hdr brachytx 1 channel,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77786,Hdr brachytx 2-12 channel,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77787,Hdr brachytx over 12 chan,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77789,Apply surf ldr radionuclide,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77790,Radiation handling,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,77799,Radium/radioisotope therapy,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78012,Thyroid uptake measurement,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78013,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78014,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78015,Thyroid met imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78016,Thyroid met imaging/studies,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78018,Thyroid met imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78020,Thyroid met uptake,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78070,Parathyroid planar imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78071,Parathyrd planar w/wo subtrj,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78072,Parathyrd planar w/spect&ct,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78075,Adrenal cortex & medulla img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78099,Endocrine nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78102,Bone marrow imaging ltd,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78103,Bone marrow imaging mult,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78104,Bone marrow imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78110,Plasma volume single,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78111,Plasma volume multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78120,Red cell mass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78121,Red cell mass multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78122,Blood volume,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78130,Red cell survival study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78135,Red cell survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78140,Red cell sequestration,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78185,Spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78190,Platelet survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78191,Platelet survival,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78195,Lymph system imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78199,Blood/lymph nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78201,Liver imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78202,Liver imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78205,Liver imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78206,Liver image (3d) with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78215,Liver and spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78216,Liver & spleen image/flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78226,Hepatobiliary system imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78227,Hepatobil syst image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78230,Salivary gland imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78231,Serial salivary imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78232,Salivary gland function exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78258,Esophageal motility study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78261,Gastric mucosa imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78262,Gastroesophageal reflux exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78264,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78265,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78266,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78267,Breath tst attain/anal c-14,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78270,Vit b-12 absorption exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78271,Vit b-12 absrp exam int fac,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78272,Vit b-12 absorp combined,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78278,Acute gi blood loss imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78282,Gi protein loss exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78290,Meckels divert exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78291,Leveen/shunt patency exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78299,Gi nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78300,Bone imaging limited area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78305,Bone imaging multiple areas,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78306,Bone imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78315,Bone imaging 3 phase,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78320,Bone imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78350,Bone mineral single photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78351,Bone mineral dual photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78399,Musculoskeletal nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78414,Non-imaging heart function,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78428,Cardiac shunt imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78429,Myocrd img pet 1 std w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78430,Myocrd img pet rst/strs w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78431,Myocrd img pet rst&strs ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78432,Myocrd img pet 2rtracer,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78433,Myocrd img pet 2rtracer ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78434,Aqmbf pet rest & rx stress,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78445,Vascular flow imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78451,Ht muscle image spect sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78452,Ht muscle image spect mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78453,Ht muscle image planar sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78454,Ht musc image planar mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78456,Acute venous thrombus image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78457,Venous thrombosis imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78458,Ven thrombosis images bilat,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78459,Myocrd img pet single study,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78466,Heart infarct image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78468,Heart infarct image (ef),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78469,Heart infarct image (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78472,Gated heart planar single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78473,Gated heart multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78481,Heart first pass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78483,Heart first pass multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78491,Myocrd img pet 1std rst/strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78492,Myocrd img pet mlt rst&strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78494,Heart image spect,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78496,Heart first pass add-on,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78499,Cardiovascular nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78579,Lung ventilation imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78580,Lung perfusion imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78582,Lung ventilat&perfus imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78597,Lung perfusion differential,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78598,Lung perf&ventilat diferentl,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78599,Respiratory nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78600,Brain image < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78601,Brain image w/flow < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78605,Brain image 4+ views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78606,Brain image w/flow 4 + views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78607,Brain imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78608,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78609,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78610,Brain flow imaging only,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78630,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78635,Csf ventriculography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78645,Csf shunt evaluation,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78647,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78650,Csf leakage imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78660,Nuclear exam of tear flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78699,Nervous system nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78700,Kidney imaging morphol,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78701,Kidney imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78707,K flow/funct image w/o drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78708,K flow/funct image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78709,K flow/funct image multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78710,Kidney imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78725,Kidney function study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78730,Urinary bladder retention,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78740,Ureteral reflux study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78761,Testicular imaging w/flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78799,Genitourinary nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78800,Rp loclzj tum 1 area 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78801,Rp loclzj tum 2+area 1+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78802,Rp loclzj tum whbdy 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78803,Rp loclzj tum spect 1 area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78804,Rp loclzj tum whbdy 2+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78805,Abscess imaging ltd area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78806,Abscess imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78807,Nuclear localization/abscess,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78811,Pet image ltd area,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78812,Pet image skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78813,Pet image full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78814,Pet image w/ct lmtd,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78815,Pet image w/ct skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78816,Pet image w/ct full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78830,Rp loclzj tum spect w/ct 1,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78831,Rp loclzj tum spect 2 areas,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78832,Rp loclzj tum spect w/ct 2,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78835,Rp quan meas single area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,78999,Nuclear diagnostic exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,79005,Nuclear rx oral admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,79101,Nuclear rx iv admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,79200,Nuclear rx intracav admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,79300,Nuclr rx interstit colloid,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,79403,Hematopoietic nuclear tx,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,79440,Nuclear rx intra-articular,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,79445,Nuclear rx intra-arterial,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,79999,Nuclear medicine therapy,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80047,Metabolic panel ionized ca,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80048,Metabolic panel total ca,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80050,General health panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80051,Electrolyte panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80053,Comprehen metabolic panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80055,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80061,Lipid panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80069,Renal function panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80074,Acute hepatitis panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80076,Hepatic function panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80081,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80143,Drug assay acetaminophen,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80145,Drug assay adalimumab,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80150,Assay of amikacin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80151,Drug assay amiodarone,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80155,Drug assay caffeine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80156,Assay carbamazepine total,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80157,Assay carbamazepine free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80158,Drug assay cyclosporine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80159,Drug assay clozapine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80161,"Asy carbamazepin 10,11-epxid",Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80162,Assay of digoxin total,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80163,Assay of digoxin free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80164,Assay dipropylacetic acd tot,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80165,Dipropylacetic acid free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80167,Drug assay felbamate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80168,Assay of ethosuximide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80169,Drug assay everolimus,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80170,Assay of gentamicin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80171,Drug screen quant gabapentin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80173,Assay of haloperidol,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80175,Drug screen quan lamotrigine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80176,Assay of lidocaine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80177,Drug scrn quan levetiracetam,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80178,Assay of lithium,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80179,Drug assay salicylate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80180,Drug scrn quan mycophenolate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80181,Drug assay flecainide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80183,Drug scrn quant oxcarbazepin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80184,Assay of phenobarbital,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80185,Assay of phenytoin total,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80186,Assay of phenytoin free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80187,Drug assay posaconazole,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80188,Assay of primidone,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80189,Drug assay itraconzaole,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80190,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80192,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80193,Drug assay leflunomide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80194,Assay of quinidine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80195,Assay of sirolimus,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80197,Assay of tacrolimus,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80198,Assay of theophylline,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80199,Drug screen quant tiagabine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80200,Assay of tobramycin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80201,Assay of topiramate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80202,Assay of vancomycin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80203,Drug screen quant zonisamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80204,Drug assay methotrexate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80210,Drug assay rufinamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80230,Drug assay infliximab,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80235,Drug assay lacosamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80280,Drug assay vedolizumab,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80285,Drug assay voriconazole,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80299,Quantitative assay drug,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80300,Drug screen non tlc devices,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80301,Drug screen class list a,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80302,Drug screen prsmptv 1 class,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80303,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80304,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80305,Drug test prsmv dir opt obs,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80306,Drug test prsmv instrmnt,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80307,Drug test prsmv chem anlyzr,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80320,Drug screen quantalcohols,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80321,Alcohols biomarkers 1or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80322,Alcohols biomarkers 3/more,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80323,Alkaloids nos,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80324,Drug screen amphetamines 1/2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80325,Amphetamines 3or 4,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80326,Amphetamines 5 or more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80327,Anabolic steroid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80328,Anabolic steroid 3 or more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80329,Analgesics non-opioid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80330,Analgesics non-opioid 3-5,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80331,Analgesics non-opioid 6/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80332,Antidepressants class 1 or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80333,Antidepressants class 3-5,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80334,Antidepressants class 6/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80335,Antidepressant tricyclic 1/2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80336,Antidepressant tricyclic 3-5,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80337,Tricyclic & cyclicals 6/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80338,Antidepressant not specified,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80339,Antiepileptics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80340,Antiepileptics nos 4-6,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80341,Antiepileptics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80342,Antipsychotics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80343,Antipsychotics nos 4-6,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80344,Antipsychotics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80345,Drug screening barbiturates,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80346,Benzodiazepines1-12,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80347,Benzodiazepines 13 or more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80348,Drug screening buprenorphine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80349,Cannabinoids natural,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80350,Cannabinoids synthetic 1-3,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80351,Cannabinoids synthetic 4-6,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80352,Cannabinoid synthetic 7/more,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80353,Drug screening cocaine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80354,Drug screening fentanyl,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80355,Gabapentin non-blood,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80356,Heroin metabolite,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80357,Ketamine and norketamine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80358,Drug screening methadone,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80359,Methylenedioxyamphetamines,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80360,Methylphenidate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80361,Opiates 1 or more,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80362,Opioids & opiate analogs 1/2,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80363,Opioids & opiate analogs 3/4,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80364,Opioid &opiate analog 5/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80365,Drug screening oxycodone,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80366,Drug screening pregabalin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80367,Drug screening propoxyphene,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80368,Sedative hypnotics,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80369,Skeletal muscle relaxant 1/2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80370,Skel musc relaxant 3 or more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80371,Stimulants synthetic,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80372,Drug screening tapentadol,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80373,Drug screening tramadol,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80374,Stereoisomer analysis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80375,Drug/substance nos 1-3,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80376,Drug/substance nos 4-6,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80377,Drug/substance nos 7/more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80400,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80402,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80406,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80408,Aldosterone suppression eval,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80410,Calcitonin stimul panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80412,Crh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80414,Testosterone response panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80415,Tot estradiol response panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80416,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80417,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80418,Pituitary evaluation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80420,Dexamethasone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80422,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80424,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80426,Gonadotropin hormone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80428,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80430,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80432,Insulin suppression panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80434,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80435,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80436,Metyrapone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80438,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80439,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80500,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,80502,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81000,Urinalysis nonauto w/scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81001,Urinalysis auto w/scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81002,Urinalysis nonauto w/o scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81003,Urinalysis auto w/o scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81005,Urinalysis,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81007,Urine screen for bacteria,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81015,Microscopic exam of urine,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81020,Urinalysis glass test,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81025,Urine pregnancy test,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81050,Urinalysis volume measure,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81099,Urinalysis test procedure,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81105,Hpa-1 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81106,Hpa-2 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81107,Hpa-3 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81108,Hpa-4 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81109,Hpa-5 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81110,Hpa-6 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81111,Hpa-9 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81112,Hpa-15 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81120,Idh1 common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81121,Idh2 common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81161,Dmd dup/delet analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81162,Brca1&2 gen full seq dup/del,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81163,Brca1&2 gene full seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81164,Brca1&2 gen ful dup/del alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81165,Brca1 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81166,Brca1 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81167,Brca2 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81168,Ccnd1/igh translocation alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81170,Abl1 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81171,Aff2 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81172,Aff2 gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81173,Ar gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81174,Ar gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81175,Asxl1 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81176,Asxl1 gene target seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81177,Atn1 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81178,Atxn1 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81179,Atxn2 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81180,Atxn3 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81181,Atxn7 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81182,Atxn8os gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81183,Atxn10 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81184,Cacna1a gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81185,Cacna1a gene full gene seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81186,Cacna1a gen known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81187,Cnbp gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81188,Cstb gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81189,Cstb gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81190,Cstb gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81191,Ntrk1 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81192,Ntrk2 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81193,Ntrk3 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81194,Ntrk translocation analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81200,Aspa gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81201,Apc gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81202,Apc gene known fam variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81203,Apc gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81204,Ar gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81205,Bckdhb gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81206,Bcr/abl1 gene major bp,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81207,Bcr/abl1 gene minor bp,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81208,Bcr/abl1 gene other bp,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81209,Blm gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81210,Braf gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81211,Brca1&2 seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81212,Brca1&2 185&5385&6174 vrnt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81213,Brca1&2 uncom dup/del var,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81214,Brca1 full seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81215,Brca1 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81216,Brca2 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81217,Brca2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81218,Cebpa gene full sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81219,Calr gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81220,Cftr gene com variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81221,Cftr gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81222,Cftr gene dup/delet variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81223,Cftr gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81224,Cftr gene intron poly t,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81225,Cyp2c19 gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81226,Cyp2d6 gene com variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81227,Cyp2c9 gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81228,Cytogen micrarray copy nmbr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81229,Cytogen m array copy no&snp,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81230,Cyp3a4 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81231,Cyp3a5 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81232,Dpyd gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81233,Btk gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81234,Dmpk gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81235,Egfr gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81236,Ezh2 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81237,Ezh2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81238,F9 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81239,Dmpk gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81240,F2 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81241,F5 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81242,Fancc gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81243,Fmr1 gene detection,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81244,Fmr1 gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81245,Flt3 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81246,Flt3 gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81247,G6pd gene alys cmn variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81248,G6pd known familial variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81249,G6pd full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81250,G6pc gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81251,Gba gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81252,Gjb2 gene full sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81253,Gjb2 gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81254,Gjb6 gene com variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81255,Hexa gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81256,Hfe gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81257,Hba1/hba2 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81258,Hba1/hba2 gene fam vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81259,Hba1/hba2 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81260,Ikbkap gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81261,Igh gene rearrange amp meth,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81262,Igh gene rearrang dir probe,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81263,Igh vari regional mutation,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81264,Igk rearrangeabn clonal pop,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81265,Str markers specimen anal,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81266,Str markers spec anal addl,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81267,Chimerism anal no cell selec,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81268,Chimerism anal w/cell select,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81269,Hba1/hba2 gene dup/del vrnts,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81270,Jak2 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81271,Htt gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81272,Kit gene targeted seq analys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81273,Kit gene analys d816 variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81274,Htt gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81275,Kras gene variants exon 2,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81276,Kras gene addl variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81277,Cytogenomic neo microra alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81278,Igh/bcl2 translocation alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81279,Jak2 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81280,Long qt synd gene full seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81281,Long qt synd known fam var,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81282,Long qt syn gene dup/dlt var,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81283,Ifnl3 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81284,Fxn gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81285,Fxn gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81286,Fxn gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81287,Mgmt gene prmtr mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81288,Mlh1 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81289,Fxn gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81290,Mcoln1 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81291,Mthfr gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81292,Mlh1 gene full seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81293,Mlh1 gene known variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81294,Mlh1 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81295,Msh2 gene full seq,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81296,Msh2 gene known variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81297,Msh2 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81298,Msh6 gene full seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81299,Msh6 gene known variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81300,Msh6 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81301,Microsatellite instability,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81302,Mecp2 gene full seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81303,Mecp2 gene known variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81304,Mecp2 gene dup/delet variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81305,Myd88 gene p.leu265pro vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81306,Nudt15 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81307,Palb2 gene full gene seq,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81308,Palb2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81309,Pik3ca gene trgt seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81310,Npm1 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81311,Nras gene variants exon 2&3,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81312,Pabpn1 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81313,Pca3/klk3 antigen,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81314,Pdgfra gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81315,Pml/raralpha com breakpoints,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81316,Pml/raralpha 1 breakpoint,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81317,Pms2 gene full seq analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81318,Pms2 known familial variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81319,Pms2 gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81320,Plcg2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81321,Pten gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81322,Pten gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81323,Pten gene dup/delet variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81324,Pmp22 gene dup/delet,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81325,Pmp22 gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81326,Pmp22 gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81327,Sept9 gen prmtr mthyltn alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81328,Slco1b1 gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81329,Smn1 gene dos/deletion alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81330,Smpd1 gene common variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81331,Snrpn/ube3a gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81332,Serpina1 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81333,Tgfbi gene common variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81334,Runx1 gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81335,Tpmt gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81336,Smn1 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81337,Smn1 gen nown famil seq vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81338,Mpl gene common variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81339,Mpl gene seq alys exon 10,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81340,Trb@ gene rearrange amplify,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81341,Trb@ gene rearrange dirprobe,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81342,Trg gene rearrangement anal,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81343,Ppp2r2b gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81344,Tbp gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81345,Tert gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81346,Tyms gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81347,Sf3b1 gene common variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81348,Srsf2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81350,Ugt1a1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81351,Tp53 gene full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81352,Tp53 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81353,Tp53 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81355,Vkorc1 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81357,U2af1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81360,Zrsr2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81361,Hbb gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81362,Hbb gene known fam variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81363,Hbb gene dup/del variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81364,Hbb full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81370,Hla i & ii typing lr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81371,Hla i & ii type verify lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81372,Hla i typing complete lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81373,Hla i typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81374,Hla i typing 1 antigen lr,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81375,Hla ii typing ag equiv lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81376,Hla ii typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81377,Hla ii type 1 ag equiv lr,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81378,Hla i & ii typing hr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81379,Hla i typing complete hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81380,Hla i typing 1 locus hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81381,Hla i typing 1 allele hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81382,Hla ii typing 1 loc hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81383,Hla ii typing 1 allele hr,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81400,Mopath procedure level 1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81401,Mopath procedure level 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81402,Mopath procedure level 3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81403,Mopath procedure level 4,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81404,Mopath procedure level 5,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81405,Mopath procedure level 6,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81406,Mopath procedure level 7,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81407,Mopath procedure level 8,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81408,Mopath procedure level 9,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81410,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81411,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81412,Ashkenazi jewish assoc dis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81413,Car ion chnnlpath inc 10 gns,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81414,Car ion chnnlpath inc 2 gns,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81415,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81416,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81417,Exome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81419,Epilepsy gen seq alys panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81420,Fetal chrmoml aneuploidy,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81422,Fetal chrmoml microdeltj,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81425,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81426,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81427,Genome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81430,Hearing loss sequence analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81431,Hearing loss dup/del analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81434,Hereditary retinal disorders,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81435,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81436,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81437,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81438,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81439,Hrdtry cardmypy gene panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81440,Mitochondrial gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81442,Noonan spectrum disorders,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81443,Genetic tstg severe inh cond,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81445,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81448,Hrdtry perph neurphy panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81450,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81455,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81460,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81465,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81470,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81471,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81479,Unlisted molecular pathology,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81490,Autoimmune rheumatoid arthr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81493,Cor artery disease mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81500,Onco (ovar) two proteins,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81503,Onco (ovar) five proteins,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81504,Oncology tissue of origin,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81506,Endo assay seven anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81507,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81508,Ftl cgen abnor two proteins,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81509,Ftl cgen abnor 3 proteins,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81510,Ftl cgen abnor three anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81511,Ftl cgen abnor four anal,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81512,Ftl cgen abnor five anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81513,Nfct ds bv rna vag flu alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81514,Nfct ds bv&vaginitis dna alg,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81518,Onc brst mrna 11 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81519,Oncology breast mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81520,Onc breast mrna 58 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81521,Onc breast mrna 70 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81522,Onc breast mrna 12 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81525,Oncology colon mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81528,Oncology colorectal scr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81529,Onc cutan mlnma mrna 31 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81535,Oncology gynecologic,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81536,Oncology gynecologic,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81538,Oncology lung,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81539,Oncology prostate prob score,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81540,Oncology tum unknown origin,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81541,Onc prostate mrna 46 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81542,Onc prostate mrna 22 cnt gen,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81545,Oncology thyroid,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81546,"Onc thyr mrna 10,196 gen alg",Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81551,Onc prostate 3 genes,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81552,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81554,Pulm ds ipf mrna 190 gen alg,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81595,Cardiology hrt trnspl mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81596,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,81599,Unlisted maaa,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82009,Test for acetone/ketones,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82010,Acetone assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82013,Acetylcholinesterase assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82016,Acylcarnitines qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82017,Acylcarnitines quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82024,Assay of acth,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82030,Assay of adp & amp,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82040,Assay of serum albumin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82042,Other source albumin quan ea,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82043,Ur albumin quantitative,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82044,Ur albumin semiquantitative,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82045,Albumin ischemia modified,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82075,Assay of breath ethanol,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82077,Assay spec xcp ur&breath ia,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82085,Assay of aldolase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82088,Assay of aldosterone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82103,Alpha-1-antitrypsin total,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82104,Alpha-1-antitrypsin pheno,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82105,Alpha-fetoprotein serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82106,Alpha-fetoprotein amniotic,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82107,Alpha-fetoprotein l3,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82108,Assay of aluminum,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82120,Amines vaginal fluid qual,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82127,Amino acid single qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82128,Amino acids mult qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82131,Amino acids single quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82135,Assay aminolevulinic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82136,Amino acids quant 2-5,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82139,Amino acids quan 6 or more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82140,Assay of ammonia,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82143,Amniotic fluid scan,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82150,Assay of amylase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82154,Androstanediol glucuronide,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82157,Assay of androstenedione,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82160,Assay of androsterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82163,Assay of angiotensin ii,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82164,Angiotensin i enzyme test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82172,Assay of apolipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82175,Assay of arsenic,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82180,Assay of ascorbic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82190,Atomic absorption,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82232,Assay of beta-2 protein,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82239,Bile acids total,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82240,Bile acids cholylglycine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82247,Bilirubin total,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82248,Bilirubin direct,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82252,Fecal bilirubin test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82261,Assay of biotinidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82270,Occult blood feces,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82271,Occult blood other sources,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82272,Occult bld feces 1-3 tests,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82274,Assay test for blood fecal,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82286,Assay of bradykinin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82300,Assay of cadmium,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82306,Vitamin d 25 hydroxy,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82308,Assay of calcitonin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82310,Assay of calcium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82330,Assay of calcium,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82331,Calcium infusion test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82340,Assay of calcium in urine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82355,Calculus analysis qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82360,Calculus assay quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82365,Calculus spectroscopy,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82370,X-ray assay calculus,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82373,Assay c-d transfer measure,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82374,Assay blood carbon dioxide,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82375,Assay carboxyhb quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82376,Assay carboxyhb qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82378,Carcinoembryonic antigen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82379,Assay of carnitine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82380,Assay of carotene,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82382,Assay urine catecholamines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82383,Assay blood catecholamines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82384,Assay three catecholamines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82387,Assay of cathepsin-d,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82390,Assay of ceruloplasmin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82397,Chemiluminescent assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82415,Assay of chloramphenicol,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82435,Assay of blood chloride,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82436,Assay of urine chloride,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82438,Assay other fluid chlorides,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82441,Test for chlorohydrocarbons,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82465,Assay bld/serum cholesterol,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82480,Assay serum cholinesterase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82482,Assay rbc cholinesterase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82485,Assay chondroitin sulfate,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82486,Gas/liquid chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82487,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82488,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82489,Thin layer chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82491,Chromotography quant sing,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82492,Chromotography quant mult,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82495,Assay of chromium,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82507,Assay of citrate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82523,Collagen crosslinks,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82525,Assay of copper,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82528,Assay of corticosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82530,Cortisol free,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82533,Total cortisol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82540,Assay of creatine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82541,Column chromotography qual,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82542,Col chromotography qual/quan,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82543,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82544,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82550,Assay of ck (cpk),Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82552,Assay of cpk in blood,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82553,Creatine mb fraction,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82554,Creatine isoforms,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82565,Assay of creatinine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82570,Assay of urine creatinine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82575,Creatinine clearance test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82585,Assay of cryofibrinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82595,Assay of cryoglobulin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82600,Assay of cyanide,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82607,Vitamin b-12,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82608,B-12 binding capacity,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82610,Cystatin c,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82615,Test for urine cystines,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82626,Dehydroepiandrosterone,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82627,Dehydroepiandrosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82633,Desoxycorticosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82634,Deoxycortisol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82638,Assay of dibucaine number,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82642,Dihydrotestosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82652,Vit d 1 25-dihydroxy,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82656,Pancreatic elastase fecal,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82657,Enzyme cell activity,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82658,Enzyme cell activity ra,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82664,Electrophoretic test,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82668,Assay of erythropoietin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82670,Assay of total estradiol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82671,Assay of estrogens,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82672,Assay of estrogen,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82677,Assay of estriol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82679,Assay of estrone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82681,Assay dir meas fr estradiol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82693,Assay of ethylene glycol,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82696,Assay of etiocholanolone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82705,Fats/lipids feces qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82710,Fats/lipids feces quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82715,Assay of fecal fat,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82725,Assay of blood fatty acids,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82726,Long chain fatty acids,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82728,Assay of ferritin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82731,Assay of fetal fibronectin,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82735,Assay of fluoride,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82746,Assay of folic acid serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82747,Assay of folic acid rbc,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82757,Assay of semen fructose,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82759,Assay of rbc galactokinase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82760,Assay of galactose,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82775,Assay galactose transferase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82776,Galactose transferase test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82777,Galectin-3,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82784,Assay iga/igd/igg/igm each,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82785,Assay of ige,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82787,Igg 1 2 3 or 4 each,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82800,Blood ph,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82803,Blood gases any combination,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82805,Blood gases w/o2 saturation,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82810,Blood gases o2 sat only,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82820,Hemoglobin-oxygen affinity,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82930,Gastric analy w/ph ea spec,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82938,Gastrin test,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82941,Assay of gastrin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82943,Assay of glucagon,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82945,Glucose other fluid,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82946,Glucagon tolerance test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82947,Assay glucose blood quant,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82948,Reagent strip/blood glucose,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82950,Glucose test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82951,Glucose tolerance test (gtt),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82952,Gtt-added samples,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82955,Assay of g6pd enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82960,Test for g6pd enzyme,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82962,Glucose blood test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82963,Assay of glucosidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82965,Assay of gdh enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82977,Assay of ggt,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82978,Assay of glutathione,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82979,Assay rbc glutathione,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,82985,Assay of glycated protein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83001,Assay of gonadotropin (fsh),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83002,Assay of gonadotropin (lh),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83003,Assay growth hormone (hgh),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83006,Growth stimulation gene 2,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83009,H pylori (c-13) blood,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83010,Assay of haptoglobin quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83012,Assay of haptoglobins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83013,H pylori (c-13) breath,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83014,H pylori drug admin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83015,Heavy metal qual any anal,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83018,Heavy metal quant each nes,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83020,Hemoglobin electrophoresis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83021,Hemoglobin chromotography,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83026,Hemoglobin copper sulfate,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83030,Fetal hemoglobin chemical,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83033,Fetal hemoglobin assay qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83036,Glycosylated hemoglobin test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83037,Glycosylated hb home device,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83045,Blood methemoglobin test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83050,Blood methemoglobin assay,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83051,Assay of plasma hemoglobin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83060,Blood sulfhemoglobin assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83065,Assay of hemoglobin heat,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83068,Hemoglobin stability screen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83069,Assay of urine hemoglobin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83070,Assay of hemosiderin qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83080,Assay of b hexosaminidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83088,Assay of histamine,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83090,Assay of homocystine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83150,Assay of homovanillic acid,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83491,Assay of corticosteroids 17,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83497,Assay of 5-hiaa,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83498,Assay of progesterone 17-d,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83499,Assay of progesterone 20-,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83500,Assay free hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83505,Assay total hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83516,Immunoassay nonantibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83518,Immunoassay dipstick,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83519,Ria nonantibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83520,Immunoassay quant nos nonab,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83525,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83527,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83528,Assay of intrinsic factor,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83540,Assay of iron,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83550,Iron binding test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83570,Assay of idh enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83582,Assay of ketogenic steroids,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83586,Assay 17- ketosteroids,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83593,Fractionation ketosteroids,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83605,Assay of lactic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83615,Lactate (ld) (ldh) enzyme,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83625,Assay of ldh enzymes,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83630,Lactoferrin fecal (qual),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83631,Lactoferrin fecal (quant),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83632,Placental lactogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83633,Test urine for lactose,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83655,Assay of lead,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83661,L/s ratio fetal lung,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83662,Foam stability fetal lung,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83663,Fluoro polarize fetal lung,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83664,Lamellar bdy fetal lung,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83670,Assay of lap enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83690,Assay of lipase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83695,Assay of lipoprotein(a),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83698,Assay lipoprotein pla2,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83700,Lipopro bld electrophoretic,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83701,Lipoprotein bld hr fraction,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83704,Lipoprotein bld quan part,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83718,Assay of lipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83719,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83721,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83722,Lipoprtn dir meas sd ldl chl,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83727,Assay of lrh hormone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83735,Assay of magnesium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83775,Assay malate dehydrogenase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83785,Assay of manganese,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83788,Mass spectrometry qual,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83789,Mass spectrometry qual/quan,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83825,Assay of mercury,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83835,Assay of metanephrines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83857,Assay of methemalbumin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83861,Microfluid analy tears,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83864,Mucopolysaccharides,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83872,Assay synovial fluid mucin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83873,Assay of csf protein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83874,Assay of myoglobin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83876,Assay myeloperoxidase,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83880,Assay of natriuretic peptide,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83883,Assay nephelometry not spec,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83885,Assay of nickel,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83915,Assay of nucleotidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83916,Oligoclonal bands,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83918,Organic acids total quant,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83919,Organic acids qual each,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83921,Organic acid single quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83930,Assay of blood osmolality,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83935,Assay of urine osmolality,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83937,Assay of osteocalcin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83945,Assay of oxalate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83950,Oncoprotein her-2/neu,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83951,Oncoprotein dcp,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83970,Assay of parathormone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83986,Assay ph body fluid nos,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83987,Exhaled breath condensate,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83992,Assay for phencyclidine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,83993,Assay for calprotectin fecal,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84030,Assay of blood pku,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84035,Assay of phenylketones,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84060,Assay acid phosphatase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84061,Phosphatase forensic exam,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84066,Assay prostate phosphatase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84075,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84078,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84080,Assay alkaline phosphatases,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84081,Assay phosphatidylglycerol,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84085,Assay of rbc pg6d enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84087,Assay phosphohexose enzymes,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84100,Assay of phosphorus,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84105,Assay of urine phosphorus,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84106,Test for porphobilinogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84110,Assay of porphobilinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84112,Eval amniotic fluid protein,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84119,Test urine for porphyrins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84120,Assay of urine porphyrins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84126,Assay of feces porphyrins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84132,Assay of serum potassium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84133,Assay of urine potassium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84134,Assay of prealbumin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84135,Assay of pregnanediol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84138,Assay of pregnanetriol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84140,Assay of pregnenolone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84143,Assay of 17-hydroxypregneno,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84144,Assay of progesterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84145,Procalcitonin (pct),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84146,Assay of prolactin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84150,Assay of prostaglandin,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84152,Assay of psa complexed,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84153,Assay of psa total,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84154,Assay of psa free,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84155,Assay of protein serum,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84156,Assay of protein urine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84157,Assay of protein other,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84160,Assay of protein any source,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84163,Pappa serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84165,Protein e-phoresis serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84166,Protein e-phoresis/urine/csf,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84181,Western blot test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84182,Protein western blot test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84202,Assay rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84203,Test rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84206,Assay of proinsulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84207,Assay of vitamin b-6,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84210,Assay of pyruvate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84220,Assay of pyruvate kinase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84228,Assay of quinine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84233,Assay of estrogen,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84234,Assay of progesterone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84235,Assay of endocrine hormone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84238,Assay nonendocrine receptor,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84244,Assay of renin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84252,Assay of vitamin b-2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84255,Assay of selenium,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84260,Assay of serotonin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84270,Assay of sex hormone globul,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84275,Assay of sialic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84285,Assay of silica,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84295,Assay of serum sodium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84300,Assay of urine sodium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84302,Assay of sweat sodium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84305,Assay of somatomedin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84307,Assay of somatostatin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84311,Spectrophotometry,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84315,Body fluid specific gravity,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84375,Chromatogram assay sugars,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84376,Sugars single qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84377,Sugars multiple qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84378,Sugars single quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84379,Sugars multiple quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84392,Assay of urine sulfate,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84402,Assay of free testosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84403,Assay of total testosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84410,Testosterone bioavailable,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84425,Assay of vitamin b-1,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84430,Assay of thiocyanate,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84431,Thromboxane urine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84432,Assay of thyroglobulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84436,Assay of total thyroxine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84437,Assay of neonatal thyroxine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84439,Assay of free thyroxine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84442,Assay of thyroid activity,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84443,Assay thyroid stim hormone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84445,Assay of tsi globulin,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84446,Assay of vitamin e,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84449,Assay of transcortin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84450,Transferase (ast) (sgot),Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84460,Alanine amino (alt) (sgpt),Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84466,Assay of transferrin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84478,Assay of triglycerides,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84479,Assay of thyroid (t3 or t4),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84480,Assay triiodothyronine (t3),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84481,Free assay (ft-3),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84482,T3 reverse,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84484,Assay of troponin quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84485,Assay duodenal fluid trypsin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84488,Test feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84490,Assay of feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84510,Assay of tyrosine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84512,Assay of troponin qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84520,Assay of urea nitrogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84525,Urea nitrogen semi-quant,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84540,Assay of urine/urea-n,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84545,Urea-n clearance test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84550,Assay of blood/uric acid,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84560,Assay of urine/uric acid,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84577,Assay of feces/urobilinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84578,Test urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84580,Assay of urine urobilinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84583,Assay of urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84585,Assay of urine vma,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84586,Assay of vip,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84588,Assay of vasopressin,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84590,Assay of vitamin a,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84591,Assay of nos vitamin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84597,Assay of vitamin k,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84600,Assay of volatiles,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84620,Xylose tolerance test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84630,Assay of zinc,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84681,Assay of c-peptide,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84702,Chorionic gonadotropin test,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84703,Chorionic gonadotropin assay,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84704,Hcg free betachain test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84830,Ovulation tests,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,84999,Clinical chemistry test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85002,Bleeding time test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85004,Automated diff wbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85007,Bl smear w/diff wbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85008,Bl smear w/o diff wbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85009,Manual diff wbc count b-coat,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85013,Spun microhematocrit,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85014,Hematocrit,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85018,Hemoglobin,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85025,Complete cbc w/auto diff wbc,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85027,Complete cbc automated,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85032,Manual cell count each,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85041,Automated rbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85044,Manual reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85045,Automated reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85046,Reticyte/hgb concentrate,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85048,Automated leukocyte count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85049,Automated platelet count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85055,Reticulated platelet assay,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85060,Blood smear interpretation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85097,Bone marrow interpretation,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85130,Chromogenic substrate assay,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85170,Blood clot retraction,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85175,Blood clot lysis time,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85210,Clot factor ii prothrom spec,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85220,Blooc clot factor v test,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85230,Clot factor vii proconvertin,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85240,Clot factor viii ahg 1 stage,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85244,Clot factor viii reltd antgn,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85245,Clot factor viii vw ristoctn,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85246,Clot factor viii vw antigen,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85247,Clot factor viii multimetric,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85250,Clot factor ix ptc/chrstmas,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85260,Clot factor x stuart-power,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85270,Clot factor xi pta,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85280,Clot factor xii hageman,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85290,Clot factor xiii fibrin stab,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85291,Clot factor xiii fibrin scrn,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85292,Clot factor fletcher fact,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85293,Clot factor wght kininogen,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85300,Antithrombin iii activity,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85301,Antithrombin iii antigen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85302,Clot inhibit prot c antigen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85303,Clot inhibit prot c activity,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85305,Clot inhibit prot s total,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85306,Clot inhibit prot s free,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85307,Assay activated protein c,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85335,Factor inhibitor test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85337,Thrombomodulin,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85345,Coagulation time lee & white,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85347,Coagulation time activated,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85348,Coagulation time otr method,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85360,Euglobulin lysis,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85362,Fibrin degradation products,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85366,Fibrinogen test,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85370,Fibrinogen test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85378,Fibrin degrade semiquant,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85379,Fibrin degradation quant,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85380,Fibrin degradj d-dimer,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85384,Fibrinogen activity,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85385,Fibrinogen antigen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85390,Fibrinolysins screen i&r,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85396,Clotting assay whole blood,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85397,Clotting funct activity,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85400,Fibrinolytic plasmin,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85410,Fibrinolytic antiplasmin,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85415,Fibrinolytic plasminogen,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85420,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85421,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85441,Heinz bodies direct,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85445,Heinz bodies induced,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85460,Hemoglobin fetal,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85461,Hemoglobin fetal,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85475,Hemolysin acid,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85520,Heparin assay,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85525,Heparin neutralization,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85530,Heparin-protamine tolerance,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85536,Iron stain peripheral blood,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85540,Wbc alkaline phosphatase,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85547,Rbc mechanical fragility,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85549,Muramidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85555,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85557,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85576,Blood platelet aggregation,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85597,Phospholipid pltlt neutraliz,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85598,Hexagnal phosph pltlt neutrl,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85610,Prothrombin time,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85611,Prothrombin test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85612,Viper venom prothrombin time,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85613,Russell viper venom diluted,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85635,Reptilase test,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85651,Rbc sed rate nonautomated,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85652,Rbc sed rate automated,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85660,Rbc sickle cell test,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85670,Thrombin time plasma,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85675,Thrombin time titer,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85705,Thromboplastin inhibition,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85730,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85732,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85810,Blood viscosity examination,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,85999,Hematology procedure,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86000,Agglutinins febrile antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86001,Allergen specific igg,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86003,Allg spec ige crude xtrc ea,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86005,Allg spec ige multiallg scr,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86008,Allg spec ige recomb ea,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86021,Wbc antibody identification,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86022,Platelet antibodies,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86023,Immunoglobulin assay,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86038,Antinuclear antibodies,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86039,Antinuclear antibodies (ana),Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86060,Antistreptolysin o titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86063,Antistreptolysin o screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86140,C-reactive protein,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86141,C-reactive protein hs,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86146,Beta-2 glycoprotein antibody,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86147,Cardiolipin antibody ea ig,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86148,Anti-phospholipid antibody,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86152,Cell enumeration & id,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86153,Cell enumeration phys interp,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86155,Chemotaxis assay,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86156,Cold agglutinin screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86157,Cold agglutinin titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86160,Complement antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86161,Complement/function activity,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86162,Complement total (ch50),Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86171,Complement fixation each,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86185,Counterimmunoelectrophoresis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86200,Ccp antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86215,Deoxyribonuclease antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86225,Dna antibody native,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86226,Dna antibody single strand,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86235,Nuclear antigen antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86243,Fc receptor,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86255,Fluorescent antibody screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86256,Fluorescent antibody titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86277,Growth hormone antibody,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86280,Hemagglutination inhibition,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86294,Immunoassay tumor qual,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86300,Immunoassay tumor ca 15-3,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86301,Immunoassay tumor ca 19-9,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86304,Immunoassay tumor ca 125,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86305,Human epididymis protein 4,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86308,Heterophile antibody screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86309,Heterophile antibody titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86310,Heterophile antibody absrbj,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86316,Immunoassay tumor other,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86317,Immunoassay infectious agent,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86318,Ia infectious agent antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86320,Serum immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86325,Other immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86327,Immunoelectrophoresis assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86328,Ia nfct ab sarscov2 covid19,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86329,Immunodiffusion nes,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86331,Immunodiffusion ouchterlony,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86332,Immune complex assay,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86334,Immunofix e-phoresis serum,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86335,Immunfix e-phorsis/urine/csf,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86336,Inhibin a,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86337,Insulin antibodies,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86340,Intrinsic factor antibody,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86341,Islet cell antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86343,Leukocyte histamine release,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86344,Leukocyte phagocytosis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86352,Cell function assay w/stim,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86353,Lymphocyte transformation,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86355,B cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86356,Mononuclear cell antigen,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86357,Nk cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86359,T cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86360,T cell absolute count/ratio,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86361,T cell absolute count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86367,Stem cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86376,Microsomal antibody each,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86378,Migration inhibitory factor,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86382,Neutralization test viral,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86384,Nitroblue tetrazolium dye,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86386,Nuclear matrix protein 22,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86403,Particle agglut antbdy scrn,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86406,Particle agglut antbdy titr,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86408,Neutrlzg antb sarscov2 scr,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86409,Neutrlzg antb sarscov2 titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86413,Sars-cov-2 antb quantitative,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86430,Rheumatoid factor test qual,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86431,Rheumatoid factor quant,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86480,Tb test cell immun measure,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86481,Tb ag response t-cell susp,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86485,Skin test candida,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86486,Skin test nos antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86490,Coccidioidomycosis skin test,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86510,Histoplasmosis skin test,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86580,Tb intradermal test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86590,Streptokinase antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86592,Syphilis test non-trep qual,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86593,Syphilis test non-trep quant,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86602,Antinomyces antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86603,Adenovirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86606,Aspergillus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86609,Bacterium antibody,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86611,Bartonella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86612,Blastomyces antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86615,Bordetella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86617,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86618,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86619,Borrelia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86622,Brucella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86625,Campylobacter antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86628,Candida antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86631,Chlamydia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86632,Chlamydia igm antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86635,Coccidioides antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86638,Q fever antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86641,Cryptococcus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86644,Cmv antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86645,Cmv antibody igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86648,Diphtheria antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86651,Encephalitis californ antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86652,Encephaltis east eqne anbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86653,Encephaltis st louis antbody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86654,Encephaltis west eqne antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86658,Enterovirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86663,Epstein-barr antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86664,Epstein-barr nuclear antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86665,Epstein-barr capsid vca,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86666,Ehrlichia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86668,Francisella tularensis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86671,Fungus nes antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86674,Giardia lamblia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86677,Helicobacter pylori antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86682,Helminth antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86684,Hemophilus influenza antibdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86687,Htlv-i antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86688,Htlv-ii antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86689,Htlv/hiv confirmj antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86692,Hepatitis delta agent antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86694,Herpes simplex nes antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86695,Herpes simplex type 1 test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86696,Herpes simplex type 2 test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86698,Histoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86701,Hiv-1antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86702,Hiv-2 antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86704,Hep b core antibody total,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86705,Hep b core antibody igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86706,Hep b surface antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86707,Hepatitis be antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86708,Hepatitis a antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86709,Hepatitis a igm antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86710,Influenza virus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86711,John cunningham antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86713,Legionella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86717,Leishmania antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86720,Leptospira antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86723,Listeria monocytogenes,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86727,Lymph choriomeningitis ab,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86729,Lympho venereum antibody,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86732,Mucormycosis antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86735,Mumps antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86738,Mycoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86741,Neisseria meningitidis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86744,Nocardia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86747,Parvovirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86750,Malaria antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86753,Protozoa antibody nos,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86756,Respiratory virus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86757,Rickettsia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86759,Rotavirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86762,Rubella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86765,Rubeola antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86768,Salmonella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86769,Sars-cov-2 covid-19 antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86771,Shigella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86774,Tetanus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86777,Toxoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86778,Toxoplasma antibody igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86780,Treponema pallidum,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86784,Trichinella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86787,Varicella-zoster antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86788,West nile virus ab igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86789,West nile virus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86790,Virus antibody nos,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86793,Yersinia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86794,Zika virus igm antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86800,Thyroglobulin antibody,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86803,Hepatitis c ab test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86804,Hep c ab test confirm,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86805,Lymphocytotoxicity assay,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86806,Lymphocytotoxicity assay,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86807,Cytotoxic antibody screening,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86808,Cytotoxic antibody screening,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86812,Hla typing a b or c,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86813,Hla typing a b or c,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86816,Hla typing dr/dq,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86817,Hla typing dr/dq,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86821,Lymphocyte culture mixed,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86822,Lymphocyte culture primed,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86825,Hla x-math non-cytotoxic,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86826,Hla x-match noncytotoxc addl,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86828,Hla class i&ii antibody qual,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86829,Hla class i/ii antibody qual,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86830,Hla class i phenotype qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86831,Hla class ii phenotype qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86832,Hla class i high defin qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86833,Hla class ii high defin qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86834,Hla class i semiquant panel,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86835,Hla class ii semiquant panel,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86849,Immunology procedure,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86850,Rbc antibody screen,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86860,Rbc antibody elution,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86870,Rbc antibody identification,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86880,Coombs test direct,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86885,Coombs test indirect qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86886,Coombs test indirect titer,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86900,Blood typing serologic abo,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86901,Blood typing serologic rh(d),Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86902,Blood type antigen donor ea,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86904,Blood typing patient serum,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86905,Blood typing rbc antigens,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86906,Bld typing serologic rh phnt,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86910,Blood typing paternity test,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86911,Blood typing antigen system,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86920,Compatibility test spin,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86921,Compatibility test incubate,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86922,Compatibility test antiglob,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86923,Compatibility test electric,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86940,Hemolysins/agglutinins auto,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86941,Hemolysins/agglutinins,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,86999,Transfusion procedure,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87003,Small animal inoculation,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87015,Specimen infect agnt concntj,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87040,Blood culture for bacteria,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87045,Feces culture aerobic bact,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87046,Stool cultr aerobic bact ea,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87070,Culture othr specimn aerobic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87071,Culture aerobic quant other,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87073,Culture bacteria anaerobic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87075,Cultr bacteria except blood,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87076,Culture anaerobe ident each,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87077,Culture aerobic identify,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87081,Culture screen only,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87084,Culture of specimen by kit,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87086,Urine culture/colony count,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87088,Urine bacteria culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87101,Skin fungi culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87102,Fungus isolation culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87103,Blood fungus culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87106,Fungi identification yeast,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87107,Fungi identification mold,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87109,Mycoplasma,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87110,Chlamydia culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87116,Mycobacteria culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87118,Mycobacteric identification,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87140,Culture type immunofluoresc,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87143,Culture typing glc/hplc,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87147,Culture type immunologic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87149,Dna/rna direct probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87150,Dna/rna amplified probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87152,Culture type pulse field gel,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87158,Culture typing added method,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87164,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87166,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87168,Macroscopic exam arthropod,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87169,Macroscopic exam parasite,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87172,Pinworm exam,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87176,Tissue homogenization cultr,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87177,Ova and parasites smears,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87181,Microbe susceptible diffuse,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87184,Microbe susceptible disk,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87185,Microbe susceptible enzyme,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87186,Microbe susceptible mic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87187,Microbe susceptible mlc,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87188,Microbe suscept macrobroth,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87190,Microbe suscept mycobacteri,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87197,Bactericidal level serum,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87205,Smear gram stain,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87206,Smear fluorescent/acid stai,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87207,Smear special stain,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87209,Smear complex stain,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87210,Smear wet mount saline/ink,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87220,Tissue exam for fungi,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87230,Assay toxin or antitoxin,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87250,Virus inoculate eggs/animal,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87252,Virus inoculation tissue,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87253,Virus inoculate tissue addl,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87254,Virus inoculation shell via,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87255,Genet virus isolate hsv,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87260,Adenovirus ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87265,Pertussis ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87267,Enterovirus antibody dfa,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87269,Giardia ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87270,Chlamydia trachomatis ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87271,Cytomegalovirus dfa,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87272,Cryptosporidium ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87273,Herpes simplex 2 ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87274,Herpes simplex 1 ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87275,Influenza b ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87276,Influenza a ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87277,Legionella micdadei ag if,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87278,Legion pneumophilia ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87279,Parainfluenza ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87280,Respiratory syncytial ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87281,Pneumocystis carinii ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87283,Rubeola ag if,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87285,Treponema pallidum ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87290,Varicella zoster ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87299,Antibody detection nos if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87300,Ag detection polyval if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87301,Adenovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87305,Aspergillus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87320,Chylmd trach ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87324,Clostridium ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87327,Cryptococcus neoform ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87328,Cryptosporidium ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87329,Giardia ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87332,Cytomegalovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87335,E coli 0157 ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87336,Entamoeb hist dispr ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87337,Entamoeb hist group ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87338,Hpylori stool ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87339,H pylori ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87340,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87341,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87350,Hepatitis be ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87380,Hepatitis delta agent ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87385,Histoplasma capsul ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87390,Hiv-1 ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87391,Hiv-2 ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87400,Influenza a/b each ag ia,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87420,Resp syncytial virus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87425,Rotavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87426,Sarscov coronavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87427,Shiga-like toxin ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87428,Sarscov & inf vir a&b ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87430,Strep a ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87449,Nos each organism ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87450,Ag detect nos ia single,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87451,Polyvalent mult org ea ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87470,Bartonella dna dir probe,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87471,Bartonella dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87472,Bartonella dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87475,Lyme dis dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87476,Lyme dis dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87477,Lyme dis dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87480,Candida dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87481,Candida dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87482,Candida dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87485,Chylmd pneum dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87486,Chylmd pneum dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87487,Chylmd pneum dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87490,Chylmd trach dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87491,Chylmd trach dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87492,Chylmd trach dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87493,C diff amplified probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87495,Cytomeg dna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87496,Cytomeg dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87497,Cytomeg dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87498,Enterovirus probe&revrs trns,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87500,Vanomycin dna amp probe,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87501,Influenza dna amp prob 1+,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87502,Influenza dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87503,Influenza dna amp prob addl,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87510,Gardner vag dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87511,Gardner vag dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87512,Gardner vag dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87515,Hepatitis b dna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87516,Hepatitis b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87517,Hepatitis b dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87520,Hepatitis c rna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87521,Hepatitis c probe&rvrs trnsc,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87522,Hepatitis c revrs trnscrpj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87525,Hepatitis g dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87526,Hepatitis g dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87527,Hepatitis g dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87528,Hsv dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87529,Hsv dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87530,Hsv dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87531,Hhv-6 dna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87532,Hhv-6 dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87533,Hhv-6 dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87534,Hiv-1 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87535,Hiv-1 probe&reverse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87536,Hiv-1 quant&revrse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87537,Hiv-2 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87538,Hiv-2 probe&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87539,Hiv-2 quant&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87540,Legion pneumo dna dir prob,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87541,Legion pneumo dna amp prob,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87542,Legion pneumo dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87550,Mycobacteria dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87551,Mycobacteria dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87552,Mycobacteria dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87555,M.tuberculo dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87556,M.tuberculo dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87557,M.tuberculo dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87560,M.avium-intra dna dir prob,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87561,M.avium-intra dna amp prob,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87562,M.avium-intra dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87563,M. genitalium amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87580,M.pneumon dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87581,M.pneumon dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87590,N.gonorrhoeae dna dir prob,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87591,N.gonorrhoeae dna amp prob,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87592,N.gonorrhoeae dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87623,Hpv low-risk types,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87624,Hpv high-risk types,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87625,Hpv types 16 & 18 only,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87634,Rsv dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87635,Sars-cov-2 covid-19 amp prb,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87636,Sarscov2 & inf a&b amp prb,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87640,Staph a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87641,Mr-staph dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87650,Strep a dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87651,Strep a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87652,Strep a dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87653,Strep b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87660,Trichomonas vagin dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87661,Trichomonas vaginalis amplif,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87662,Zika virus dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87797,Detect agent nos dna dir,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87798,Detect agent nos dna amp,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87799,Detect agent nos dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87800,Detect agnt mult dna direc,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87801,Detect agnt mult dna ampli,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87802,Strep b assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87803,Clostridium toxin a w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87804,Influenza assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87806,Hiv w/hiv1&2 antb w/optic,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87807,Rsv assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87808,Trichomonas assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87809,Adenovirus assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87810,Chylmd trach assay w/optic,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87811,Sars-cov-2 covid19 w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87850,N. gonorrhoeae assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87880,Strep a assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87899,Agent nos assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87904,Phenotype dna hiv w/clt add,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87905,Sialidase enzyme assay,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,87999,Microbiology procedure,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88104,Cytopath fl nongyn smears,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88106,Cytopath fl nongyn filter,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88108,Cytopath concentrate tech,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88112,Cytopath cell enhance tech,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88120,Cytp urne 3-5 probes ea spec,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88125,Forensic cytopathology,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88130,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88140,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88141,Cytopath c/v interpret,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88142,Cytopath c/v thin layer,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88143,Cytopath c/v thin layer redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88147,Cytopath c/v automated,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88148,Cytopath c/v auto rescreen,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88150,Cytopath c/v manual,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88152,Cytopath c/v auto redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88153,Cytopath c/v redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88154,Cytopath c/v select,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88155,Cytopath c/v index add-on,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88160,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88161,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88162,Cytopath smear other source,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88164,Cytopath tbs c/v manual,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88165,Cytopath tbs c/v redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88166,Cytopath tbs c/v auto redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88167,Cytopath tbs c/v select,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88172,Cytp dx eval fna 1st ea site,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88173,Cytopath eval fna report,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88174,Cytopath c/v auto in fluid,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88175,Cytopath c/v auto fluid redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88177,Cytp fna eval ea addl,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88182,Cell marker study,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88184,Flowcytometry/ tc 1 marker,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88187,Flowcytometry/read 2-8,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88188,Flowcytometry/read 9-15,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88189,Flowcytometry/read 16 & >,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88199,Cytopathology procedure,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88240,Cell cryopreserve/storage,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88241,Frozen cell preparation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88245,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88248,Chromosome analysis 50-100,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88249,Chromosome analysis 100,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88261,Chromosome analysis 5,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88262,Chromosome analysis 15-20,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88263,Chromosome analysis 45,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88264,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88267,Chromosome analys placenta,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88269,Chromosome analys amniotic,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88271,Cytogenetics dna probe,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88272,Cytogenetics 3-5,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88273,Cytogenetics 10-30,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88274,Cytogenetics 25-99,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88275,Cytogenetics 100-300,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88280,Chromosome karyotype study,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88283,Chromosome banding study,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88285,Chromosome count additional,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88289,Chromosome study additional,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88291,Cyto/molecular report,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88299,Cytogenetic study,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88300,Surgical path gross,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88302,Tissue exam by pathologist,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88304,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88305,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88311,Decalcify tissue,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88312,Special stains group 1,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88313,Special stains group 2,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88314,Histochemical stains add-on,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88321,Microslide consultation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88323,Microslide consultation,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88325,Comprehensive review of data,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88329,Path consult introp,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88331,Path consult intraop 1 bloc,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88332,Path consult intraop addl,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88333,Intraop cyto path consult 1,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88334,Intraop cyto path consult 2,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88342,Immunohisto antb 1st stain,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88346,Immunofluor antb 1st stain,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88347,Immunofluorescent study,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88355,Analysis skeletal muscle,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88356,Analysis nerve,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88358,Analysis tumor,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88363,Xm archive tissue molec anal,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88364,Insitu hybridization (fish),Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88369,M/phmtrc alysishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88371,Protein western blot tissue,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88372,Protein analysis w/probe,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88373,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88374,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88375,Optical endomicroscpy interp,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88377,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88380,Microdissection laser,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88381,Microdissection manual,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88387,Tiss exam molecular study,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88388,Tiss ex molecul study add-on,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88399,Surgical pathology procedure,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88720,Bilirubin total transcut,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88738,Hgb quant transcutaneous,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88740,Transcutaneous carboxyhb,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88741,Transcutaneous methb,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,88749,In vivo lab service,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89050,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89051,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89055,Leukocyte assessment fecal,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89060,Exam synovial fluid crystals,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89125,Specimen fat stain,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89160,Exam feces for meat fibers,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89190,Nasal smear for eosinophils,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89220,Sputum specimen collection,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89230,Collect sweat for test,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89240,Pathology lab procedure,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89250,Cultr oocyte/embryo <4 days,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89253,Embryo hatching,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89254,Oocyte identification,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89255,Prepare embryo for transfer,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89257,Sperm identification,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89260,Sperm isolation simple,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89261,Sperm isolation complex,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89264,Identify sperm tissue,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89281,Assist oocyte fertilization,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89290,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89291,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89300,Semen analysis w/huhner,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89310,Semen analysis w/count,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89320,Semen anal vol/count/mot,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89321,Semen anal sperm detection,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89322,Semen anal strict criteria,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89325,Sperm antibody test,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89329,Sperm evaluation test,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89330,Evaluation cervical mucus,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89331,Retrograde ejaculation anal,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89335,Cryopreserve testicular tiss,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89353,Thawing cryopresrved sperm,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,89398,Unlisted reprod med lab proc,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90287,Botulinum antitoxin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90288,Botulism ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90291,Cmv ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90371,Hep b ig im,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90375,Rabies ig im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90376,Rabies ig heat treated,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90377,Rabies ig ht&sol human im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90378,Rsv mab im 50mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90384,Rh ig full-dose im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90386,Rh ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90389,Tetanus ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90393,Vaccina ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90396,Varicella-zoster ig im,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90460,Im admin 1st/only component,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90461,Im admin each addl component,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90471,Immunization admin,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90472,Immunization admin each add,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90473,Immune admin oral/nasal,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90474,Immune admin oral/nasal addl,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90476,Adenovirus vaccine type 4,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90477,Adenovirus vaccine type 7,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90581,Anthrax vaccine sc or im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90585,Bcg vaccine percut,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90586,Bcg vaccine intravesical,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90587,Dengue vacc quad 3 dose subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90619,Menacwy-tt vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90620,Menb-4c vacc 2 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90621,Menb-fhbp vacc 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90625,Cholera vaccine live oral,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90630,Flu vacc iiv4 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90632,Hepa vaccine adult im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90633,Hepa vacc ped/adol 2 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90634,Hepa vacc ped/adol 3 dose,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90636,Hep a/hep b vacc adult im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90644,Hib-mency vacc 6wk-18m0 im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90645,Hib vaccine hboc im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90646,Hib vaccine prp-d im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90647,Hib prp-omp vacc 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90648,Hib prp-t vaccine 4 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90649,4vhpv vaccine 3 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90650,2vhpv vaccine 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90651,9vhpv vaccine 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90653,Iiv adjuvant vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90654,Flu vacc iiv3 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90658,Iiv3 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90660,Laiv3 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90662,Iiv no prsv increased ag im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90664,Laiv vacc pandemic intranasl,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90666,Flu vac pandem prsrv free im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90667,Iiv vacc pandemic adjuvt im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90668,Iiv vaccine pandemic im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90669,Pneumococcal vacc 7 val im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90670,Pcv13 vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90672,Laiv4 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90673,Riv3 vaccine no preserv im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90675,Rabies vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90676,Rabies vaccine id,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90680,Rv5 vacc 3 dose live oral,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90681,Rv1 vacc 2 dose live oral,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90682,Riv4 vacc recombinant dna im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90690,Typhoid vaccine oral,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90691,Typhoid vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90692,Typhoid vaccine h-p sc/id,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90693,Typhoid vaccine akd sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90696,Dtap-ipv vaccine 4-6 yrs im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90697,Dtap-ipv-hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90698,Dtap-ipv/hib vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90700,Dtap vaccine < 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90702,Dt vaccine under 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90703,Tetanus vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90704,Mumps vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90705,Measles vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90706,Rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90707,Mmr vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90708,Measles-rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90710,Mmrv vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90712,Oral poliovirus vaccine,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90713,Poliovirus ipv sc/im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90714,Td vacc no presv 7 yrs+ im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90715,Tdap vaccine 7 yrs/> im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90716,Var vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90717,Yellow fever vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90719,Diphtheria vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90720,Dtp/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90721,Dtap/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90723,Dtap-hep b-ipv vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90725,Cholera vaccine injectable,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90727,Plague vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90733,Mpsv4 vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90734,Menacwyd/menacwycrm vacc im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90735,Encephalitis vaccine sc,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90736,Hzv vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90738,Inactivated je vacc im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90739,Hepb vacc 2 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90740,Hepb vacc 3 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90743,Hepb vacc 2 dose adolesc im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90744,Hepb vacc 3 dose ped/adol im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90746,Hepb vaccine 3 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90747,Hepb vacc 4 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90748,Hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90749,Vaccine toxoid,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90750,Hzv vacc recombinant im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90756,Cciiv4 vacc abx free im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90785,Psytx complex interactive,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90791,Psych diagnostic evaluation,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90792,Psych diag eval w/med srvcs,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90832,Psytx w pt 30 minutes,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90833,Psytx w pt w e/m 30 min,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90834,Psytx w pt 45 minutes,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90836,Psytx w pt w e/m 45 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90837,Psytx w pt 60 minutes,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90838,Psytx w pt w e/m 60 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90839,Psytx crisis initial 60 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90840,Psytx crisis ea addl 30 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90845,Psychoanalysis,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90846,Family psytx w/o pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90847,Family psytx w/pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90849,Multiple family group psytx,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90853,Group psychotherapy,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90863,Pharmacologic mgmt w/psytx,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90865,Narcosynthesis,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90867,Tcranial magn stim tx plan,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90868,Tcranial magn stim tx deli,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90869,Tcran magn stim redetemine,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90870,Electroconvulsive therapy,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90875,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90876,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90880,Hypnotherapy,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90882,Environmental manipulation,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90885,Psy evaluation of records,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90887,Consultation with family,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90889,Preparation of report,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90899,Psychiatric service/therapy,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90901,Biofeedback train any meth,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90911,Biofeedback peri/uro/rectal,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90912,Bfb training 1st 15 min,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90913,Bfb training ea addl 15 min,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90935,Hemodialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90937,Hemodialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90940,Hemodialysis access study,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90945,Dialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90947,Dialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90989,Dialysis training complete,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90993,Dialysis training incompl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90997,Hemoperfusion,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,90999,Dialysis procedure,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91010,Esophagus motility study,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91013,Esophgl motil w/stim/perfus,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91020,Gastric motility studies,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91022,Duodenal motility study,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91030,Acid perfusion of esophagus,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91034,Gastroesophageal reflux test,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91035,G-esoph reflx tst w/electrod,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91037,Esoph imped function test,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91038,Esoph imped funct test > 1hr,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91040,Esoph balloon distension tst,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91110,Gi tract capsule endoscopy,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91111,Esophageal capsule endoscopy,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91112,Gi wireless capsule measure,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91117,Colon motility 6 hr study,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91120,Rectal sensation test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91122,Anal pressure record,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91132,Electrogastrography,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91133,Electrogastrography w/test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91200,Liver elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91299,Gastroenterology procedure,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91302,Coronavirus vaccine 3,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91303,Coronavirus vaccine 4,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91304,Coronavirus vaccine 5,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91305,Coronavirus vaccine 6,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91306,Coronavirus vaccine 7,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91307,Coronavirus vaccine 8,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91308,Coronavirus vaccine 9,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91309,Coronavirus vaccine 10,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,91310,Coronavirus vaccine 11,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92015,Determine refractive state,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92018,New eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92019,Eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92020,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92025,Corneal topography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92060,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92065,Orthoptic/pleoptic training,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92071,Contact lens fitting for tx,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92072,Fit contac lens for managmnt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92081,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92082,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92083,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92100,Serial tonometry exam(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92132,Cmptr ophth dx img ant segmt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92133,Cmptr ophth img optic nerve,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92134,Cptr ophth dx img post segmt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92136,Ophthalmic biometry,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92140,Glaucoma provocative tests,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92145,Corneal hysteresis deter,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92201,Opscpy extnd rta draw uni/bi,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92202,Opscpy extnd on/mac draw,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92225,Special eye exam initial,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92226,Special eye exam subsequent,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92227,Img rta detcj/mntr ds staff,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92228,Img rta detc/mntr ds phy/qhp,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92229,Img rta detc/mntr ds poc aly,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92230,Eye exam with photos,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92235,Fluorescein angrph uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92240,Icg angiography uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92242,Fluorescein icg angiography,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92250,Eye exam with photos,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92260,Ophthalmoscopy/dynamometry,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92265,Eye muscle evaluation,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92270,Electro-oculography,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92273,Full field erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92274,Multifocal erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92275,Electroretinography,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92283,Color vision examination,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92284,Dark adaptation eye exam,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92285,Eye photography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92286,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92287,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92310,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92311,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92312,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92313,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92314,Prescription of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92315,Rx cntact lens aphakia 1 eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92316,Rx cntact lens aphakia 2 eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92317,Rx corneoscleral cntact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92325,Modification of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92326,Replacement of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92340,Fit spectacles monofocal,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92341,Fit spectacles bifocal,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92342,Fit spectacles multifocal,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92352,Fit aphakia spectcl monofocl,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92353,Fit aphakia spectcl multifoc,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92354,Fit spectacles single system,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92355,Fit spectacles compound lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92358,Aphakia prosth service temp,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92370,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92371,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92499,Eye service or procedure,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92507,Speech/hearing therapy,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92516,Facial nerve function test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92517,Vemp test i&r cervical,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92518,Vemp test i&r ocular,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92519,Vemp tst i&r cervical&ocular,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92520,Laryngeal function studies,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92521,Evaluation of speech fluency,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92522,Evaluate speech production,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92523,Speech sound lang comprehen,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92524,Behavral qualit analys voice,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92534,Optokinetic nystagmus test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92537,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92538,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92540,Basic vestibular evaluation,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92543,Caloric vestibular test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92546,Sinusoidal rotational test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92547,Supplemental electrical test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92548,Cdp-sot 6 cond w/i&r,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92550,Tympanometry & reflex thresh,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92553,Audiometry air & bone,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92557,Comprehensive hearing test,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92558,Evoked auditory test qual,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92570,Acoustic immitance testing,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92572,Staggered spondaic word test,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92577,Stenger test speech,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92579,Visual audiometry (vra),Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92582,Conditioning play audiometry,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92584,Electrocochleography,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92585,Auditor evoke potent compre,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92586,Auditor evoke potent limit,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92587,Evoked auditory test limited,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92588,Evoked auditory tst complete,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92597,Oral speech device eval,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92601,Cochlear implt f/up exam <7,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92602,Reprogram cochlear implt <7,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92603,Cochlear implt f/up exam 7/>,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92604,Reprogram cochlear implt 7/>,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92605,Ex for nonspeech device rx,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92606,Non-speech device service,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92607,Ex for speech device rx 1hr,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92608,Ex for speech device rx addl,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92610,Evaluate swallowing function,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92618,Ex for nonspeech dev rx add,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92620,Auditory function 60 min,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92621,Auditory function + 15 min,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92625,Tinnitus assessment,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92626,Eval aud funcj 1st hour,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92627,Eval aud funcj ea addl 15,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92630,Aud rehab pre-ling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92633,Aud rehab postling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92651,Aep hearing status deter i&r,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92652,Aep thrshld est mlt freq i&r,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92653,Aep neurodiagnostic i&r,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92920,Prq cardiac angioplast 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92921,Prq cardiac angio addl art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92924,Prq card angio/athrect 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92925,Prq card angio/athrect addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92928,Prq card stent w/angio 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92929,Prq card stent w/angio addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92933,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92934,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92937,Prq revasc byp graft 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92938,Prq revasc byp graft addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92941,Prq card revasc mi 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92943,Prq card revasc chronic 1vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92944,Prq card revasc chronic addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92950,Heart/lung resuscitation cpr,General Medicine,Per Unit,$385.17 ,OP,$385.17 ,$385.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92953,Temporary external pacing,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92960,Cardioversion electric ext,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92961,Cardioversion electric int,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92971,Cardioassist external,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92973,Prq coronary mech thrombect,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92975,Dissolve clot heart vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92977,Dissolve clot heart vessel,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92978,Endoluminl ivus oct c 1st,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92979,Endoluminl ivus oct c ea,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92986,Revision of aortic valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92987,Revision of mitral valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92990,Revision of pulmonary valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92997,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,92998,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93000,Electrocardiogram complete,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93005,Electrocardiogram tracing,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93010,Electrocardiogram report,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93015,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93016,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93017,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93018,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93024,Cardiac drug stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93025,Microvolt t-wave assess,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93040,Rhythm ecg with report,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93041,Rhythm ecg tracing,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93042,Rhythm ecg report,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93050,Art pressure waveform analys,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93224,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93225,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93226,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93227,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93228,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93229,Remote 30 day ecg tech supp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93241,Ext ecg>48hr<7d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93242,Ext ecg>48hr<7d recording,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93243,Ext ecg>48hr<7d scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93244,Ext ecg>48hr<7d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93245,Ext ecg>7d<15d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93246,Ext ecg>7d<15d recording,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93247,Ext ecg>7d<15d scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93248,Ext ecg>7d<15d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93260,Prgrmg dev eval impltbl sys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93261,Interrogate subq defib,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93264,Rem mntr wrls p-art prs snr,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93268,Ecg record/review,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93270,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93271,Ecg/monitoring and analysis,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93272,Ecg/review interpret only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93278,Ecg/signal-averaged,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93279,Prgrmg dev eval pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93280,Pm device progr eval dual,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93281,Pm device progr eval multi,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93282,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93283,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93284,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93285,Prgrmg dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93286,Peri-px eval pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93287,Peri-px device eval & prgr,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93288,Interrog evl pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93289,Interrog device eval heart,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93290,Interrog dev eval icpms ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93291,Interrog dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93292,Wcd device interrogate,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93293,Pm phone r-strip device eval,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93294,Rem interrog evl pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93295,Dev interrog remote 1/2/mlt,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93296,Rem interrog evl pm/ids,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93297,Rem interrog dev eval icpms,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93298,Rem interrog dev eval scrms,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93299,Interrog eval icpms/scrms,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93303,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93304,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93306,Tte w/doppler complete,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93307,Tte w/o doppler complete,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93308,Tte f-up or lmtd,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93312,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93313,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93314,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93315,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93316,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93317,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93318,Echo transesophageal intraop,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93320,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93321,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93325,Doppler color flow add-on,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93350,Stress tte only,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93351,Stress tte complete,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93352,Admin ecg contrast agent,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93355,Echo transesophageal (tee),Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93356,Myocrd strain img spckl trck,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93451,Right heart cath,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93452,Left hrt cath w/ventrclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93453,R&l hrt cath w/ventriclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93454,Coronary artery angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93455,Coronary art/grft angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93456,R hrt coronary artery angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93457,R hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93458,L hrt artery/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93459,L hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93460,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93461,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93462,L hrt cath trnsptl puncture,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93464,Exercise w/hemodynamic meas,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93505,Biopsy of heart lining,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93530,Rt heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93531,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93532,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93533,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93600,Bundle of his recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93602,Intra-atrial recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93603,Right ventricular recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93609,Map tachycardia add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93610,Intra-atrial pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93612,Intraventricular pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93613,Electrophys map 3d add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93615,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93616,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93618,Heart rhythm pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93619,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93620,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93621,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93622,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93623,Stimulation pacing heart,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93624,Electrophysiologic study,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93631,Heart pacing mapping,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93640,Evaluation heart device,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93641,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93642,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93644,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93650,Ablate heart dysrhythm focus,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93653,Ep & ablate supravent arrhyt,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93654,Ep & ablate ventric tachy,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93655,Ablate arrhythmia add on,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93656,Tx atrial fib pulm vein isol,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93657,Tx l/r atrial fib addl,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93660,Tilt table evaluation,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93662,Intracardiac ecg (ice),Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93668,Peripheral vascular rehab,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93701,Bioimpedance cv analysis,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93702,Bis xtracell fluid analysis,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93724,Analyze pacemaker system,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93745,Set-up cardiovert-defibrill,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93750,Interrogation vad in person,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93770,Measure venous pressure,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93784,Ambl bp mntr w/software,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93786,Ambl bp mntr w/sw rec only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93788,Ambl bp mntr w/sw a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93790,Ambl bp mntr w/sw i&r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93792,Pt/caregiver traing home inr,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93793,Anticoag mgmt pt warfarin,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93797,Cardiac rehab,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93798,Cardiac rehab/monitor,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93799,Cardiovascular procedure,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93880,Extracranial bilat study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93882,Extracranial uni/ltd study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93886,Intracranial complete study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93888,Intracranial limited study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93890,Tcd vasoreactivity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93892,Tcd emboli detect w/o inj,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93893,Tcd emboli detect w/inj,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93895,Carotid intima atheroma eval,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93922,Upr/l xtremity art 2 levels,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93923,Upr/lxtr art stdy 3+ lvls,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93924,Lwr xtr vasc stdy bilat,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93925,Lower extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93926,Lower extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93930,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93931,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93965,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93970,Extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93971,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93975,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93976,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93978,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93979,Vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93980,Penile vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93981,Penile vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93982,Aneurysm pressure sens study,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93985,Dup-scan hemo compl bi std,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93986,Dup-scan hemo compl uni std,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93990,Doppler flow testing,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,93998,Noninvas vasc dx study proc,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94002,Vent mgmt inpat init day,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94003,Vent mgmt inpat subq day,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94004,Vent mgmt nf per day,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94005,Home vent mgmt supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94010,Breathing capacity test,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94011,Spirometry up to 2 yrs old,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94012,Spirmtry w/brnchdil inf-2 yr,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94013,Meas lung vol thru 2 yrs,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94014,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94015,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94016,Review patient spirometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94060,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94070,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94150,Vital capacity test,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94200,Lung function test (mbc/mvv),Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94250,Expired gas collection,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94375,Respiratory flow volume loop,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94400,Co2 breathing response curve,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94450,Hypoxia response curve,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94452,Hast w/report,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94453,Hast w/oxygen titrate,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94610,Surfactant admin thru tube,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94617,Exercise tst brncspsm w/ecg,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94618,Pulmonary stress testing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94619,Exercise tst brncspsm wo ecg,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94620,Pulmonary stress test/simple,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94621,Cardiopulm exercise testing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94640,Airway inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94642,Aerosol inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94644,Cbt 1st hour,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94645,Cbt each addl hour,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94660,Pos airway pressure cpap,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94662,Neg press ventilation cnp,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94664,Evaluate pt use of inhaler,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94667,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94668,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94669,Mechanical chest wall oscill,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94680,Exhaled air analysis o2,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94681,Exhaled air analysis o2/co2,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94690,Exhaled air analysis,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94726,Pulm funct tst plethysmograp,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94727,Pulm function test by gas,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94728,Airwy resist by oscillometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94729,Co/membane diffuse capacity,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94750,Pulmonary compliance study,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94762,Measure blood oxygen level,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94770,Exhaled carbon dioxide test,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94772,Breath recording infant,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94774,Ped home apnea rec compl,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94775,Ped home apnea rec hk-up,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94776,Ped home apnea rec downld,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94777,Ped home apnea rec report,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94780,Cars/bd tst inft-12mo 60 min,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94781,Cars/bd tst inft-12mo +30min,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,94799,Pulmonary service/procedure,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95004,Percut allergy skin tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95012,Exhaled nitric oxide meas,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95017,Perq & icut allg test venoms,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95018,Perq&ic allg test drugs/biol,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95024,Icut allergy test drug/bug,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95027,Icut allergy titrate-airborn,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95028,Icut allergy test-delayed,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95044,Allergy patch tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95052,Photo patch test,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95056,Photosensitivity tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95060,Eye allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95065,Nose allergy test,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95070,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95071,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95076,Ingest challenge ini 120 min,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95079,Ingest challenge addl 60 min,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95115,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95117,Immunotherapy injections,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95120,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95125,Immunotherapy 2/> injections,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95130,Immntx 1 sting insect,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95131,Immntx 2 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95132,Immntx 3 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95133,Immntx 4 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95134,Immntx 5 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95144,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95145,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95146,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95147,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95148,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95149,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95165,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95170,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95180,Rapid desensitization,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95199,Allergy immunology services,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95249,Cont gluc mntr pt prov eqp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95250,Cont gluc mntr phys/qhp eqp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95251,Cont gluc mntr analysis i&r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95700,Eeg cont rec w/vid eeg tech,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95705,Eeg w/o vid 2-12 hr unmntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95706,Eeg wo vid 2-12hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95707,Eeg w/o vid 2-12hr cont mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95708,Eeg wo vid ea 12-26hr unmntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95709,Eeg w/o vid ea 12-26hr intmt,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95710,Eeg w/o vid ea 12-26hr cont,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95711,Veeg 2-12 hr unmonitored,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95712,Veeg 2-12 hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95713,Veeg 2-12 hr cont mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95714,Veeg ea 12-26 hr unmntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95715,Veeg ea 12-26hr intmt mntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95716,Veeg ea 12-26hr cont mntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95717,Eeg phys/qhp 2-12 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95718,Eeg phys/qhp 2-12 hr w/veeg,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95719,Eeg phys/qhp ea incr w/o vid,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95720,Eeg phy/qhp ea incr w/veeg,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95721,Eeg phy/qhp>36<60 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95722,Eeg phy/qhp>36<60 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95723,Eeg phy/qhp>60<84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95724,Eeg phy/qhp>60<84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95725,Eeg phy/qhp>84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95726,Eeg phy/qhp>84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95782,Polysom <6 yrs 4/> paramtrs,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95783,Polysom <6 yrs cpap/bilvl,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95803,Actigraphy testing,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95805,Multiple sleep latency test,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95807,Sleep study attended,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95808,Polysom any age 1-3> param,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95810,Polysom 6/> yrs 4/> param,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95811,Polysom 6/>yrs cpap 4/> parm,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95812,Eeg 41-60 minutes,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95813,Eeg extnd mntr 61-119 min,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95816,Eeg awake and drowsy,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95819,Eeg awake and asleep,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95822,Eeg coma or sleep only,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95824,Eeg cerebral death only,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95827,Eeg all night recording,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95829,Surgery electrocorticogram,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95836,Ecog impltd brn npgt <30 d,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95857,Cholinesterase challenge,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95860,Muscle test one limb,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95861,Muscle test 2 limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95863,Muscle test 3 limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95864,Muscle test 4 limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95865,Muscle test larynx,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95866,Muscle test hemidiaphragm,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95867,Muscle test cran nerv unilat,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95868,Muscle test cran nerve bilat,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95869,Muscle test thor paraspinal,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95870,Muscle test nonparaspinal,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95872,Muscle test one fiber,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95873,Guide nerv destr elec stim,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95874,Guide nerv destr needle emg,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95875,Limb exercise test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95885,Musc tst done w/nerv tst lim,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95886,Musc test done w/n test comp,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95887,Musc tst done w/n tst nonext,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95905,Motor &/ sens nrve cndj test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95907,Nvr cndj tst 1-2 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95908,Nrv cndj tst 3-4 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95909,Nrv cndj tst 5-6 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95910,Nrv cndj test 7-8 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95911,Nrv cndj test 9-10 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95912,Nrv cndj test 11-12 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95913,Nrv cndj test 13/> studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95921,Autonomic nrv parasym inervj,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95922,Autonomic nrv adrenrg inervj,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95923,Autonomic nrv syst funj test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95924,Ans parasymp & symp w/tilt,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95925,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95926,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95927,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95928,C motor evoked uppr limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95929,C motor evoked lwr limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95930,Visual ep test cns w/i&r,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95933,Blink reflex test,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95937,Neuromuscular junction test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95938,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95939,C motor evoked upr&lwr limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95943,Parasymp&symp hrt rate test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95950,Ambulatory eeg monitoring,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95951,Eeg monitoring/videorecord,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95953,Eeg monitoring/computer,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95954,Eeg monitoring/giving drugs,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95955,Eeg during surgery,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95956,Eeg monitor technol attended,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95957,Eeg digital analysis,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95958,Eeg monitoring/function test,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95965,Meg spontaneous,Diagnostic Radiology,Per Unit,$221.34 ,OP,$221.34 ,$221.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95966,Meg evoked single,Diagnostic Radiology,Per Unit,$221.34 ,OP,$221.34 ,$221.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95967,Meg evoked each addl,Diagnostic Radiology,Per Unit,$221.34 ,OP,$221.34 ,$221.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95970,Alys npgt w/o prgrmg,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95971,Alys smpl sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95972,Alys cplx sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95973,Analyze neurostim complex,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95974,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95975,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95976,Alys smpl cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95977,Alys cplx cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95978,Analyze neurostim brain/1h,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95979,Analyz neurostim brain addon,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95980,Io anal gast n-stim init,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95981,Io anal gast n-stim subsq,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95982,Io ga n-stim subsq w/reprog,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95983,Alys brn npgt prgrmg 15 min,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95984,Alys brn npgt prgrmg addl 15,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,95999,Neurological procedure,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96000,Motion analysis video/3d,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96001,Motion test w/ft press meas,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96002,Dynamic surface emg,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96003,Dynamic fine wire emg,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96020,Functional brain mapping,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96101,Psycho testing by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96102,Psycho testing by technician,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96103,Psycho testing admin by comp,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96105,Assessment of aphasia,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96110,Developmental screen w/score,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96111,Developmental test extend,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96112,Devel tst phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96113,Devel tst phys/qhp ea addl,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96116,Nubhvl xm phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96118,Neuropsych tst by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96119,Neuropsych testing by tec,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96120,Neuropsych tst admin w/comp,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96121,Nubhvl xm phy/qhp ea addl hr,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96125,Cognitive test by hc pro,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96127,Brief emotional/behav assmt,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96130,Psycl tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96131,Psycl tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96132,Nrpsyc tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96133,Nrpsyc tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96137,Psycl/nrpsyc tst phy/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96138,Psycl/nrpsyc tech 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96139,Psycl/nrpsyc tst tech ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96146,Psycl/nrpsyc tst auto result,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96150,Assess hlth/behave init,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96151,Assess hlth/behave subseq,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96153,Intervene hlth/behave group,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96154,Interv hlth/behav fam w/pt,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96155,Interv hlth/behav fam no pt,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96156,Hlth bhv assmt/reassessment,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96160,Pt-focused hlth risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96161,Caregiver health risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96360,Hydration iv infusion init,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96361,Hydrate iv infusion add-on,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96365,Ther/proph/diag iv inf init,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96366,Ther/proph/diag iv inf addon,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96367,Tx/proph/dg addl seq iv inf,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96368,Ther/diag concurrent inf,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96369,Sc ther infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96370,Sc ther infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96371,Sc ther infusion reset pump,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96413,Chemo iv infusion 1 hr,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96415,Chemo iv infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96416,Chemo prolong infuse w/pump,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96417,Chemo iv infus each addl seq,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96422,Chemo ia infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96423,Chemo ia infuse each addl hr,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96425,Chemotherapy infusion method,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96446,Chemotx admn prtl cavity,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96450,Chemotherapy into cns,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96549,Chemotherapy unspecified,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96567,Pdt dstr prmlg les skn,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96570,Photodynmc tx 30 min add-on,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96571,Photodynamic tx addl 15 min,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96573,Pdt dstr prmlg les phys/qhp,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96574,Dbrdmt prmlg les w/pdt,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96900,Ultraviolet light therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96902,Trichogram,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96913,Photochemotherapy uv-a or b,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96920,Laser tx skin < 250 sq cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96921,Laser tx skin 250-500 sq cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96922,Laser tx skin >500 sq cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96931,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96932,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96933,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96934,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96935,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96936,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,96999,Dermatological procedure,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97001,Pt evaluation,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97002,Pt re-evaluation,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97003,Ot evaluation,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97004,Ot re-evaluation,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97010,Hot or cold packs therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97012,Mechanical traction therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97014,Electric stimulation therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97016,Vasopneumatic device therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97018,Paraffin bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97022,Whirlpool therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97024,Diathermy eg microwave,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97026,Infrared therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97028,Ultraviolet therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97032,Electrical stimulation,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97033,Electric current therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97034,Contrast bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97035,Ultrasound therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97039,Physical therapy treatment,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97116,Gait training therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97124,Massage therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97139,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97161,Pt eval low complex 20 min,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97162,Pt eval mod complex 30 min,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97163,Pt eval high complex 45 min,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97164,Pt re-eval est plan care,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97165,Ot eval low complex 30 min,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97166,Ot eval mod complex 45 min,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97167,Ot eval high complex 60 min,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97168,Ot re-eval est plan care,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97535,Self care mngment training,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97545,Work hardening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97546,Work hardening add-on,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97755,Assistive technology assess,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97762,C/o for orthotic/prosth use,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97799,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97802,Medical nutrition indiv in,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97803,Med nutrition indiv subseq,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97804,Medical nutrition group,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97810,Acupunct w/o stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97811,Acupunct w/o stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97813,Acupunct w/stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,97814,Acupunct w/stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98925,Osteopath manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98926,Osteopath manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98927,Osteopath manj 5-6 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98928,Osteopath manj 7-8 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98929,Osteopath manj 9-10 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98940,Chiropract manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98941,Chiropract manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98942,Chiropractic manj 5 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98943,Chiropract manj xtrspinl 1/>,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98960,Self-mgmt educ & train 1 pt,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98961,Self-mgmt educ/train 2-4 pt,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,98962,Self-mgmt educ/train 5-8 pt,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99050,Medical services after hrs,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99051,Med serv eve/wkend/holiday,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99053,Med serv 10pm-8am 24 hr fac,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99058,Office emergency care,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99060,Out of office emerg med serv,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99078,Group health education,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99091,Collj & interpj data ea 30 d,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99100,Special anesthesia service,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99116,Anesthesia with hypothermia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99135,Special anesthesia procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99140,Emergency anesthesia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99143,Mod sedat phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99144,Mod sedat phys/qhp 5yrs/>,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99145,Mod sedat phys/qhp ea 15 min,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99148,Mod sed diff phys/qhp<5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99149,Mod sed diff phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99150,Mod sed diff phys/qhp add on,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99151,Mod sed same phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99152,Mod sed same phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99153,Mod sed same phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99155,Mod sed oth phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99156,Mod sed oth phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99157,Mod sed other phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99172,Ocular function screen,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99173,Visual acuity screen,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99174,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99175,Induction of vomiting,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99177,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99188,App topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99238,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99239,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99363,Anticoagulant mgmt initial,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99364,Anticoagulant mgmt subseq,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99366,Team conf w/pat by hc prof,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99367,Team conf w/o pat by phys,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99368,Team conf w/o pat by hc pro,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99374,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99375,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99377,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99378,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99379,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99380,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99406,Behav chng smoking 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99407,Behav chng smoking > 10 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99408,Audit/dast 15-30 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99409,Audit/dast over 30 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99439,Chrnc care mgmt svc ea addl,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99453,Rem mntr physiol param setup,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99454,Rem mntr physiol param dev,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99457,Rem physiol mntr 1st 20 min,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99458,Rem physiol mntr ea addl 20,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99465,Nb resuscitation,General Medicine,Per Unit,$385.17 ,OP,$385.17 ,$385.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99473,Self-meas bp pt educaj/train,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99474,Self-meas bp 2 readg bid 30d,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99483,Assmt & care pln pt cog imp,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99484,Care mgmt svc bhvl hlth cond,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99487,Cplx chrnc care 1st 60 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99489,Cplx chrnc care ea addl 30,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99490,Chrnc care mgmt svc 1st 20,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99491,Chrnc care mgmt svc 30 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99492,1st psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99493,Sbsq psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99494,1st/sbsq psyc collab care,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99495,Trans care mgmt 14 day disch,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99496,Trans care mgmt 7 day disch,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99497,Advncd care plan 30 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99498,Advncd care plan addl 30 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99503,Home visit resp therapy,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,99504,Home visit mech ventilator,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0001M,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0002M,Liver dis 10 assays w/ash,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0002U,Onc clrct 3 ur metab alg plp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0003A,Fee covid-19 vac 1 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0003M,Liver dis 10 assays w/nash,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0003U,Onc ovar 5 prtn ser alg scor,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0004A,Fee covid-19 vac 1 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0004M,Scoliosis dna alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0004U,Nfct ds dna 27 resist genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0005U,Onco prst8 3 gene ur alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0006M,Onc hep gene risk classifier,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0006U,Detc ia meds 120+ analytes,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0007M,Onc gastro 51 gene nomogram,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0008M,Onc breast risk score,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0008U,Hpylori detcj abx rstnc dna,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0009M,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0010M,Onc prostate prob score,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0010U,Nfct ds strn typ whl gen seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0012U,Germln do gene reargmt detcj,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0013A,Fee covid-19 vac 2 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0013M,Onc mrna 5 gen recr urthl ca,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0013U,Onc sld org neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0014A,Fee covid-19 vac 2 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0014M,Liver ds alys 3 bmrk srm alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0014U,Hem hmtlmf neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0015M,Adrnl cortcl tum bchm asy 25,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0015U,Rx metab advrs rx rxn dna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0016M,Onc bladder mrna 209 gen alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0017M,Onc dlbcl mrna 20 genes alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0018U,Onc thyr 10 microrna seq alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0019T,Extracorp shock wv tx ms nos,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0019U,Onc rna tiss predict alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0020U,Rx test prsmv ur w/def conf,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0021A,Fee covid-19 vac 3 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0021U,Onc prst8 detcj 8 autoantb,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0022A,Fee covid-19 vac 3 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0022U,Trgt gen seq dna&rna 23 gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0023A,Fee covid-19 vac 3 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0023U,Onc aml dna detcj/nondetcj,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0024A,Fee covid-19 vac 3 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0024U,Glyca nuc mr spectrsc quan,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0025U,Tenofovir liq chrom ur quan,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0026U,Onc thyr dna&mrna 112 genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0027U,Jak2 gene trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0028U,Cyp2d6 gene cpy nmr cmn vrnt,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0029U,Rx metab advrs trgt seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0030U,Rx metab warf trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0031A,Fee covid-19 vac 4 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0031U,Cyp1a2 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0032A,Fee covid-19 vac 4 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0032U,Comt gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0033A,Fee covid-19 vac 4 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0033U,Htr2a htr2c genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0034A,Fee covid-19 vac 4 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0034U,Tpmt nudt15 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0035U,Neuro csf prion prtn qual,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0036U,Xome tum & nml spec seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0037U,Trgt gen seq dna 324 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0038U,Vitamin d srm microsamp quan,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0039U,Dna antb 2strand hi avidity,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0040U,Bcr/abl1 gene major bp quan,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0041A,Fee covid-19 vac 5 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0041U,B brgdrferi antb 5 prtn igm,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0042A,Fee covid-19 vac 5 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0042T,Ct perfusion w/contrast cbf,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0042U,B brgdrferi antb 12 prtn igg,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0043A,Fee covid-19 vac 5 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0043U,Tbrf b grp antb 4 prtn igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0044A,Fee covid-19 vac 5 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0044U,Tbrf b grp antb 4 prtn igg,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0045U,Onc brst dux carc is 12 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0046U,Flt3 gene itd variants quan,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0047U,Onc prst8 mrna 17 gene alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0048U,Onc sld org neo dna 468 gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0049U,Npm1 gene analysis quan,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0050U,Trgt gen seq dna 194 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0051A,Fee covid-19 vac 6 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0052A,Fee covid-19 vac 6 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0052U,Lpoprtn bld w/5 maj classes,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0053A,Fee covid-19 vac 6 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0053U,Onc prst8 ca fish alys 4 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0054A,Fee covid-19 vac 6 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0054U,Rx mntr 14+ drugs & sbsts,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0055U,Card hrt trnspl 96 dna seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0056U,Hem aml dna gene reargmt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0057U,Onc sld org neo mrna 51 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0058T,Cryopreservation ovary tiss,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0058U,Onc merkel cll carc srm quan,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0059U,Onc merkel cll carc srm +/-,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0060U,Twn zyg gen seq alys chrms2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0061A,Fee covid-19 vac 7 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0062A,Fee covid-19 vac 7 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0063A,Fee covid-19 vac 7 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0063U,Neuro autism 32 amines alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0064A,Fee covid-19 vac 7 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0064U,Antb tp total&rpr ia qual,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0065U,Syfls tst nontreponemal antb,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0066U,Pamg-1 ia cervico-vag fluid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0069U,Onc clrct microrna mir-31-3p,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0071A,Fee covid-19 vac 8 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0071U,Cyp2d6 full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0072A,Fee covid-19 vac 8 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0073A,Fee covid-19 vac 8 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0074A,Fee covid-19 vac 8 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0074U,Cyp2d6 nonduplicated gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0075T,Perq stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0075U,Cyp2d6 5' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0076T,S&i stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0076U,Cyp2d6 3' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0077U,Ig paraprotein qual bld/ur,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0078U,Pain mgt opi use gnotyp pnl,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0079U,Cmprtv dna alys mlt snps,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0080U,Onc lng 5 clin rsk factr alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0081A,Fee covid-19 vac 9 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0081U,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0082A,Fee covid-19 vac 9 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0083A,Fee covid-19 vac 9 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0083U,Onc rspse chemo cntrst tomog,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0084A,Fee covid-19 vac 9 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0084U,Rbc dna gnotyp 10 bld groups,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0085T,Breath test heart reject,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0085U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0086U,Nfct ds bact&fng org id 6+,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0088U,Trnsplj kdn algrft rej 1494,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0089U,Onc mlnma prame & linc00518,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0090U,Onc cutan mlnma mrna 23 gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0091A,Fee covid-19 vac 10 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0091U,Onc clrct scr whl bld alg,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0092A,Fee covid-19 vac 10 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0093A,Fee covid-19 vac 10 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0093U,Rx mntr 65 com drugs urine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0094A,Fee covid-19 vac 10 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0094U,Genome rapid sequence alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0095U,Inflm ee elisa alys alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0096U,Hpv hi risk types male urine,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0099T,Implant corneal ring,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0100T,Prosth retina receive&gen,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0101A,Fee covid-19 vac 11 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0101T,Extracorp shockwv tx hi enrg,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0101U,Hered colon ca do 15 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0102A,Fee covid-19 vac 11 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0102U,Hered brst ca rltd do 17 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0103A,Fee covid-19 vac 11 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0103T,Holotranscobalamin,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0103U,Hered ova ca pnl 24 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0104A,Fee covid-19 vac 11 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0104U,Hered pan ca pnl 32 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0105U,Neph ckd mult eclia tum nec,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0106T,Touch quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0107T,Vibrate quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0107U,C diff tox ag detcj ia stool,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0108T,Cool quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0109T,Heat quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0109U,Id aspergillus dna 4 species,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0110T,Nos quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0111T,Rbc membranes fatty acids,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0111U,Onc colon ca kras&nras alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0112U,Iadi 16s&18s rrna genes,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0114U,Gi barretts esoph vim&ccna1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0115U,Respir iadna 18 viral&2 bact,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0116U,Rx mntr nzm ia 35+oral flu,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0117U,Pain mgmt 11 endogenous anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0118U,Trnsplj don-drv cll-fr dna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0119U,Crd ceramides liq chrom plsm,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0120U,Onc b cll lymphm mrna 58 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0121U,Sc dis vcam-1 whole blood,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0122U,Sc dis p-selectin whl blood,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0123T,Scleral fistulization,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0123U,Mchnl fragility rbc prflg,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0124U,Ftl cgen abnor 3 analytes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0125U,Ftl cgen abnor prnt comp 5,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0126T,Chd risk imt study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0126U,Ftl cgen abnor prnt comp 5 y,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0127U,Ob pe 3 analytes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0128U,Ob pe 3 analytes y chrmsm,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0129U,Hered brst ca rltd do panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0130U,Hered colon ca do mrna pnl,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0131U,Hered brst ca rltd do pnl 13,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0132U,Hered ova ca rltd do pnl 17,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0133U,Hered prst8 ca rltd do 11,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0134U,Hered pan ca mrna pnl 18 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0136U,Atm mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0137U,Palb2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0138U,Brca1 brca2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0139U,Neuro austm meas 6 c metablt,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0140U,Nfct ds fungi dna 15 trgt,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0141U,Nfct ds bact&fng gram pos,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0142U,Nfct ds bact&fng gram neg,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0145U,Drug assay 65+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0146U,Drug assay 80+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0147U,Drug assay 85+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0148U,Drug assay 100+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0149U,Drug assay 60+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0151U,Nfct bct/vir resp nfctj 33,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0152U,Nfct ds dna untrgt ngnrj seq,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0153U,Onc breast mrna 101 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0154U,Onc urthl ca rna fgfr3 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0155U,Onc brst ca dna pik3ca gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0156U,Copy number sequence alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0157U,Apc mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0158U,Mlh1 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0159U,Msh2 mrna seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0160U,Msh6 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0161U,Pms2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0162U,Hered colon ca trgt mrna pnl,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0163U,Onc clrct scr 3 prtn alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0164U,Gi ibs ia anti-cdtb&vinculin,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0165U,Peanut allg asmt epi,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0166U,Liver ds 10 biochem asy srm,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0167U,Chornc gonadotropin hcg ia,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0168U,Ftl aneuploidy dna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0169U,Nudt15&tpmt gene com vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0170U,Neuro asd rna next gen seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0171U,Trgt gen seq alys pnl dna 23,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0172T,Lumbar spine process addl,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0172U,Onc sld tum alys brca1 brca2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0173U,Psyc gen alys panel 14 genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0174U,Onc solid tumor 30 prtn trgt,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0175U,Psyc gen alys panel 15 genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0176U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0177U,Onc brst ca dna pik3ca 11,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0178T,64 lead ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0178U,Peanut allg asmt epi clin rx,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0179T,64 lead ecg w/tracing,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0179U,Onc nonsm cll lng ca alys 23,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0180U,Abo gnotyp abo 7 exons,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0181U,Co gnotyp aqp1 exon 1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0182T,Hdr elect brachytherapy,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0182U,Crom gnotyp cd55 exons 1-10,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0183U,Di gnotyp slc4a1 exon 19,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0184T,Exc rectal tumor endoscopic,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0184U,Do gnotyp art4 exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0185U,Fut1 gnotyp fut1 exon 4,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0186U,Fut2 gnotyp fut2 exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0188U,Ge gnotyp gypc exons 1-4,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0191T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0191U,In gnotyp cd44 exons 2 3 6,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0192U,Jk gnotyp slc14a1 exon 9,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0194U,Kel gnotyp kel exon 8,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0195U,Klf1 targeted sequencing,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0196U,Lu gnotyp bcam exon 3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0197U,Lw gnotyp icam4 exon 1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0198T,Ocular blood flow measure,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0199U,Sc gnotyp ermap exons 4 12,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0200U,Xk gnotyp xk exons 1-3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0201U,Yt gnotyp ache exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0203U,Ai ibd mrna xprsn prfl 17,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0204U,Onc thyr mrna xprsn alys 593,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0205T,Inirs each vessel add-on,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0205U,Oph amd alys 3 gene variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0206T,Cptr dbs alys car elec dta,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0206U,Neuro alzheimer cell aggregj,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0207T,Clear eyelid gland w/heat,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0207U,Neuro alzheimer quan imaging,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0208U,Onc mtc mrna xprsn alys 108,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0209U,Cytog const alys interrog,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0210U,Syphilis tst antb ia quan,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0211U,Onc pan-tum dna&rna gnrj seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0212T,Compre audiometry evaluation,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0212U,Rare ds gen dna alys proband,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0213U,Rare ds gen dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0214U,Rare ds xom dna alys proband,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0215T,Njx paravert w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0215U,Rare ds xom dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0216U,Neuro inh ataxia dna 12 com,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0217U,Neuro inh ataxia dna 51 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0218U,Neuro musc dys dmd seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0219U,Nfct agt hiv gnrj seq alys,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0220U,Onc brst ca ai assmt 12 feat,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0221U,Abo gnotyp next gnrj seq abo,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0222U,Rhd&rhce gntyp next gnrj seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0223T,Acoustic ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0224T,Acoustic ecg 1+ analysis,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0224U,Antibody sars-cov-2 titer(s),Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0225T,Acoustic ecg analy & reprog,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0226U,Svnt sarscov2 elisa plsm srm,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0227U,Rx asy prsmv30+rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0228T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0228U,Onc prst8 ma molec prfl alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0229T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0229U,Bcat1 promoter mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0230U,Ar full sequence analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0231U,Cacna1a full gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0232T,Njx platelet plasma,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0232U,Cstb full gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0233T,Skin glycation spectroscopy,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0233U,Fxn gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0234U,Mecp2 full gene analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0235T,Trluml perip athrc visceral,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0235U,Pten full gene analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0236T,Trluml perip athrc abd aorta,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0236U,Smn1&smn2 full gene analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0237T,Trluml perip athrc brchiocph,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0237U,Car ion chnlpthy gen seq pnl,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0238T,Trluml perip athrc iliac art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0238U,Onc lnch syn gen dna seq aly,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0239U,Trgt gen seq alys pnl 311+,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0240T,Esoph motility 3d topography,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0241T,Esoph motility w/stim/perf,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0243T,Intm msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0244T,Cont msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0249T,Ligation hemorrhoid w/us,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0253T,Insert aqueous drain device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0255T,Evasc rpr iliac art bifr s&i,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0263T,Im b1 mrw cel ther cmpl,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0264T,Im b1 mrw cel ther xcl hrvst,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0265T,Im b1 mrw cel ther hrvst onl,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0266T,Implt/rpl crtd sns dev total,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0267T,Implt/rpl crtd sns dev lead,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0268T,Implt/rpl crtd sns dev gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0269T,Rev/remvl crtd sns dev total,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0270T,Rev/remvl crtd sns dev lead,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0271T,Rev/remvl crtd sns dev gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0272T,Interrogate crtd sns dev,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0273T,Interrogate crtd sns w/pgrmg,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0278T,Tempr,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0282T,Periph field stimul trial,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0283T,Periph field stimul perm,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0284T,Periph field stimul revise,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0285T,Periph field stimul analys,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0286T,Near ifr spectrsc of wounds,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0288T,Anoscopy w/rf delivery,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0289T,Laser inc for pkp/lkp donor,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0290T,Laser inc for pkp/lkp recip,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0294T,Ins lt atrl mont pres lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0295T,Ext ecg complete,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0296T,Ext ecg recording,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0297T,Ext ecg scan w/report,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0298T,Ext ecg review and interp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0301T,Mw therapy for breast tumor,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0302T,Icar ischm mntrng sys compl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0303T,Icar ischm mntrng sys eltrd,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0304T,Icar ischm mntrng sys device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0305T,Icar ischm mntrng prgrm eval,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0306T,Icar ischm mntr interr eval,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0307T,Rmvl icar ischm mntrng dvce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0308T,Insj ocular telescope prosth,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0310T,Motor function mapping ntms,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0311T,Cal & alys cntrl artl press,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0312T,Laps impltj nstim vagus,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0313T,Laps rmvl nstim array vagus,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0314T,Laps rmvl vgl arry&pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0315T,Rmvl vagus nerve pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0316T,Replc vagus nerve pls gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0317T,Elec alys vagus nrv pls gen,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0329T,Mntr io press 24hrs/> uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0330T,Tear film img uni/bi w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0331T,Heart symp image plnr,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0332T,Heart symp image plnr spect,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0333T,Visual ep scr acuity auto,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0335T,Insj sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0337T,Endothel fxnassmnt non-invas,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0341T,Quant pupillometry w/ rprt,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0342T,Thxp apheresis w/hdl delip,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0346T,Ultrasound elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0348T,Rsa spine exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0349T,Rsa upper extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0350T,Rsa lower extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0352T,Oct brst/node i&r per spec,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0354T,Oct breast surg cavity i&r,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0355T,Gi tract capsule endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0356T,Insrt drug device for iop,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0357T,Cryopreservation oocyte(s),Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0358T,Bia whole body,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0362T,Bhv id suprt assmt ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0373T,Adapt bhv tx ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0376T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0377T,Anoscpy inj agent for incont,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0378T,Visual field assmnt rev/rprt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0379T,Vis field assmnt tech suppt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0380T,Comp animat ret imag series,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0381T,Ext h rate epi sz 14 days,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0382T,Ext h rate sz 14 day ri only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0383T,Ext h rate sz up to 30 days,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0384T,Ex h rate sz 30 day ri only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0385T,Ex h rate for sz ovr 30 day,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0386T,Ex h rate sz 30+ day ri only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0387T,Leadless c pm ins/rpl ventr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0388T,Leadless c pm remove ventr,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0389T,Prog eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0390T,Periproc eval inper ledls pm,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0391T,Intergt eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0392T,Lap es sph augment dev place,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0393T,Es sph augmnt device removal,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0394T,Hdr elctrnc skn surf brchytx,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0398T,Mrgfus strtctc les abltj,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0399T,Myocardial strain imaging,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0400T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0401T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0402T,Colgn cross-link crn med sep,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0403T,Diabetes prev standard curr,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0406T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0407T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0408T,Insj/rplc cardiac modulj sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0409T,Insj/rplc car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0412T,Rmvl cardiac modulj pls gen,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0414T,Rmvl & rpl car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0417T,Prgrmg eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0418T,Interro eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0419T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0420T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0421T,Waterjet prostate abltj cmpl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0422T,Tactile breast img uni/bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0423T,Assay secretory type ii pla2,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0424T,Insj/rplc nstim apnea compl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0425T,Insj/rplc nstim apnea sen ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0426T,Insj/rplc nstim apnea stm ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0427T,Insj/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0428T,Rmvl nstim apnea pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0429T,Rmvl nstim apnea sen ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0430T,Rmvl nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0431T,Rmvl/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0432T,Repos nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0433T,Repos nstim apnea sensing ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0434T,Interro eval npgs apnea,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0435T,Prgrmg eval npgs apnea 1 ses,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0436T,Prgrmg eval npgs apnea study,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0437T,Impltj synth rnfcmt abdl wal,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0438T,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0439T,Myocrd contrast prfuj echo,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0440T,Abltj perc uxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0441T,Abltj perc lxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0442T,Abltj perc plex/trncl nrv,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0443T,R-t spctrl alys prst8 tiss,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0446T,Insj impltbl glucose sensor,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0447T,Rmvl impltbl glucose sensor,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0448T,Remvl insj impltbl gluc sens,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0449T,Insj aqueous drain dev 1st,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0450T,Insj aqueous drain dev each,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0453T,Insj/rplcmt mech-elec ntrfce,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0457T,Remvl mech-elec skin ntrfce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0462T,Prgrmg eval aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0463T,Interrog aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0464T,Visual ep test for glaucoma,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0466T,Insj ch wal respir eltrd/ra,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0467T,Revj/rplmnt ch respir eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0468T,Rmvl ch wal respir eltrd/ra,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0469T,Rta polarize scan oc scr bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0470T,Oct skn img acquisj i&r 1st,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0471T,Oct skn img acquisj i&r addl,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0472T,Prgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0473T,Reprgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0474T,Insj aqueous drg dev io rsvr,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0475T,Rec ftl car sgl 3 ch i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0476T,Rec ftl car sgl elec tr data,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0477T,Rec ftl car sgl xrtj alys,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0478T,Rec ftl car 3 ch rev i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0481T,Njx autol wbc concentrate,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0482T,Absl quan myocrd bld flo pet,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0485T,Oct mid ear i&r unilateral,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0486T,Oct mid ear i&r bilateral,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0487T,Trvg biomchn mapg w/reprt,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0488T,Diabetes prev online/elec,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0489T,Regn cell tx scldr hands,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0490T,Regn cell tx scldr h mlt inj,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0497T,Xtrnl pt act ecg in-off conn,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0498T,Xtrnl pt act ecg r&i pr 30 d,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0499T,Cysto f/urtl strix/stenosis,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0500T,Hpv 5+ hi risk hpv types,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0501T,Cor ffr derived cor cta data,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0502T,Cor ffr data prep & transmis,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0503T,Cor ffr alys gnrj ffr mdl,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0504T,Cor ffr data review i&r,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0505T,Ev fempop artl revsc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0506T,Mac pgmt opt dns meas hfp,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0507T,Near ifr 2img mibmn glnd i&r,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0508T,Pls echo us b1 dns meas tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0509T,Pattern erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0510T,Rmvl sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0511T,Rmvl&rinsj sinus tarsi implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0514T,Intraop vis axis id pt fixj,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0515T,Insj wcs lv compl sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0517T,Insj wcs lv pg compnt,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0518T,Rmvl pg compnt wcs,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0519T,Rmvl & rplcmt pg compnt wcs,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0521T,Interrog dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0522T,Prgrmg dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0525T,Insj/rplcmt compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0527T,Insj/rplcmt iims implt mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0528T,Prgrmg dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0529T,Interrog dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0530T,Removal complete iims,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0532T,Removal iims implt mntr only,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0533T,Cont rec mvmt do 6-10 days,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0534T,Cont rec mvmt do setup&train,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0535T,Cont rec mvmt do reprt cnfig,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0536T,Cont rec mvmt do dl w/i&r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0541T,Myocardial imaging mcg,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0542T,Myocardial imaging mcg i&r,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0546T,Rf spectrsc ntraop mrgn asmt,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0547T,B1 matrl qual tst mcrind tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0548T,Tprnl balo cntnc dev bi,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0549T,Tprnl balo cntnc dev uni,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0550T,Tprnl balo cntnc dev rmvl ea,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0551T,Tprnl balo cntnc dev adjmt,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0552T,Low-level laser therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0553T,Perq tcat iliac anast implt,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0554T,B1 str & fx rsk analysis,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0556T,B1 str & fx rsk assessment,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0558T,Ct scan f/biomchn ct alys,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0563T,Evac meibomian glnd heat bi,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0564T,Onc chemo rx cytotox csc 14,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0566T,Autol cell implt adps njx,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0568T,Intro mix saline&air f/ssg,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0571T,Insj/rplcmt icds ss eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0575T,Prgrmg dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0576T,Interrog dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0577T,Ephys eval icds ss,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0578T,Rem interrog dev icds phys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0579T,Rem interrog dev icds tech,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0581T,Abltj mal brst tum perq crtx,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0582T,Trurl abltj mal prst8 tiss,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0583T,Tmpst auto tube dlvr sys,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0587T,Perq impltj/rplcmt isdns ptn,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0588T,Revision/removal isdns ptn,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0589T,Elec alys smpl prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0590T,Elec alys cplx prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0591T,Hlth&wb coaching indiv 1st,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0592T,Hlth&wb coaching indiv f-up,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0593T,Hlth&wb coaching group,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0596T,Temp fml iu vlv-pmp 1st insj,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0597T,Temp fml iu valve-pmp rplcmt,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0602T,Transdermal gfr measurements,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0603T,Transdermal gfr monitoring,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0604T,Rem oct rta dev setup&educaj,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0605T,Rem oct rta techl sprt min 8,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0607T,Rem mntr pulm flu mntr setup,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0608T,Rem mntr pulm flu mntr alys,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0609T,Mrs disc pain acquisj data,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0610T,Mrs disc pain transmis data,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0611T,Mrs disc pain alg alys data,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0615T,Eye mvmt alys w/o calbrj i&r,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0616T,Insertion of iris prosthesis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0617T,Insj iris prosth w/rmvl&insj,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0618T,Insj iris prosth sec io lens,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0619T,Cysto w/prst8 commissurotomy,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0620T,Evasc ven artlz tibl/prnl vn,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0621T,Trabeculostomy interno laser,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0622T,Trabeculostomy int lsr w/scp,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0623T,Auto quantification c plaque,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0632T,Perq tcat us abltj nrv p-art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0633T,Ct breast w/3d uni c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0634T,Ct breast w/3d uni c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0635T,Ct breast w/3d uni c-/c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0636T,Ct breast w/3d bi c-,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0637T,Ct breast w/3d bi c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0638T,Ct breast w/3d bi c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,0639T,Wrls skn snr anisotropy meas,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C1762,"Conn tiss, human(inc fascia)",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C1763,"Conn tiss, non-human",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C1849,"Skin substitute, synthetic",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C1878,Matrl for vocal cord,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C2615,"Sealant, pulmonary, liquid",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8900,"Mra w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8901,"Mra w/o cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8902,"Mra w/o fol w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8903,"Mri w/cont, breast, uni",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8904,"Mri w/o cont, breast, uni",Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8905,"Mri w/o fol w/cont, brst, un",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8906,"Mri w/cont, breast, bi",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8907,"Mri w/o cont, breast, bi",Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8908,"Mri w/o fol w/cont, breast,",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8909,"Mra w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8910,"Mra w/o cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8911,"Mra w/o fol w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8912,"Mra w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8913,"Mra w/o cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8914,"Mra w/o fol w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8918,"Mra w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8919,"Mra w/o cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8920,"Mra w/o fol w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8921,"Tte w or w/o fol w/cont, com",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8922,"Tte w or w/o fol w/cont, f/u",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8923,"2d tte w or w/o fol w/con,co",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8924,"2d tte w or w/o fol w/con,fu",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8925,"2d tee w or w/o fol w/con,in",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8926,"Tee w or w/o fol w/cont,cong",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8927,"Tee w or w/o fol w/cont, mon",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8928,"Tte w or w/o fol w/con,stres",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8929,"Tte w or wo fol wcon,doppler",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8930,"Tte w or w/o contr, cont ecg",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8931,"Mra, w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8932,"Mra, w/o dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8933,"Mra, w/o&w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8934,"Mra, w/dye, upper extremity",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8935,"Mra, w/o dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8936,"Mra, w/o&w/dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C8957,"Prolonged iv inf, req pump",General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9014,"Injection, cerliponase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9015,"C-1 esterase, haegarda",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9016,"Inj, triptorelin ext rel",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9024,"Inj, daunorubicin-cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9025,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9026,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9027,"Injection, pembrolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9028,Inj. inotuzumab ozogamicin,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9029,"Injection, guselkumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9030,Inj copanlisib,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9031,"Lutetium Lu 177 dotatate, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9032,Voretigene neparvovec-rzyl,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9033,"Inj, akynzeo",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9034,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9035,"Injection, Aristada Initio",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9036,"Injection, patisiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9037,"Injection, risperidone",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9038,Inj mogamulizumab-kpkc,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9040,"Injection, fremanezumab-vfrm",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9041,"Inj, coagulation factor xa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9042,"Inj., belrapzo 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9043,"Injection, levoleucovorin",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9044,"Injection, cemiplimab-rwlc",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9045,Moxetumomab pasudotox-tdfk,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9047,"Injection, caplacizumab-yhdp",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9048,Dexamethasone ophth insert,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9049,"Injection, tagraxofusp-erzs",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9050,"Injection, emapalumab-lzsg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9051,"Injection, omadacycline",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9052,"Injection, ravulizumab-cwv",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9053,"Inj, crizanlizumab-tmca",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9054,"Injection, lefamulin",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9055,"Inj, brexanolone",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9056,"Injection, givosiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9057,Inj cetirizine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9058,"Injection,pegfilgrastim-bmez",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9059,"Injection, meloxicam",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9061,"Injection, teprotumumab-trbw",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9062,Daratumumab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9063,"Injection, eptinezumab-jjmr",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9064,Mitomycin pyelocalyceal inst,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9065,Romidepsin non-lyophilized,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9066,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9069,Belantamab mafodontin-blmf,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9070,"Injection, tafasitamab-cxix",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9071,"Injection, viltolarsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9072,"Inj, imm glob asceniv",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9121,"Injection, argatroban",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9122,Mometasone furoate (sinuva),Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9132,"Kcentra, per i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9137,Adynovate Factor VIII recom,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9138,Nuwiq Factor VIII recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9139,"Idelvion, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9140,Afstyla factor viii recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9141,Factor viii pegylated-aucl,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9248,"Inj, clevidipine butyrate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9250,Artiss fibrin sealant,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9257,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9293,"Injection, glucarpidase",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9349,"Puraply, puraply antimic",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9352,"Neuragen nerve guide, per cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9353,"Neurawrap nerve protector,cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9354,"Veritas collagen matrix, cm2",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9355,"Neuromatrix nerve cuff, cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9356,"Tenoglide tendon prot, cm2",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9358,"Surgimend, fetal",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9359,"Implnt,bon void filler-putty",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9360,"Surgimend, neonatal",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9361,Neuromend nerve wrap,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9362,"Implnt,bon void filler-strip",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9363,Integra meshed bil wound mat,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9364,"Porcine implant, permacol",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9408,"Iodine i-131 iobenguane, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9442,"Injection, belinostat",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9443,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9444,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9445,"C-1 esterase, Ruconest",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9446,"Inj, tedizolid phosphate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9447,"Inj, phenylephrine ketorolac",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9448,Oral netupitant palonosetron,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9449,"Inj, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9450,Fluocinolone acetonide implt,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9451,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9452,"Inj, ceftolozane/tazobactam",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9453,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9454,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9455,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9456,"Inj, isavuconazonium sulfate",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9460,"Injection, cangrelor",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9465,"Injection, Durolane",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9466,"Injection, benralizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9467,Inj rituximab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9468,"Inj, factor ix, Rebinyn",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9469,Inj triamcinolone acetonide,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9470,Aripiprazole lauroxil im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9471,"Hymovis, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9472,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9473,"Injection, mepolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9474,"Inj, irinotecan liposome",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9475,"Injection, necitumumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9476,"Injection, daratumumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9477,"Injection, elotuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9478,"Injection, sebelipase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9480,"Injection, trabectedin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9481,"Injection, reslizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9482,Sotalol hydrochloride iv,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9483,"Injection, atezolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9484,"Injection, eteplirsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9485,"Injection, olaratumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9487,"Ustekinumab IV inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9488,Conivaptan hcl,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9489,"Injection, nusinersen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9490,"Injection, bezlotoxumab",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9491,"Injection, avelumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9492,"Injection, durvalumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9493,"Injection, edaravone",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9494,"Injection, ocrelizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9497,"Loxapine, inhalation powder",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9600,Perc drug-el cor stent sing,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9601,Perc drug-el cor stent bran,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9602,Perc d-e cor stent ather s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9603,Perc d-e cor stent ather br,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9604,Perc d-e cor revasc t cabg s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9605,Perc d-e cor revasc t cabg b,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9606,Perc d-e cor revasc w ami s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9607,Perc d-e cor revasc chro sin,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9608,Perc d-e cor revasc chro add,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9724,Eps stomach plic,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9726,Rxt breast appl place/remov,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9728,"Place device/marker, non pro",Therapeutic Radiology,Per Unit,$68.45 ,OP,$68.45 ,$68.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9734,"U/s trtmt, not leiomyomata",General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9737,Lap esoph augmentation,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9739,Cystoscopy prostatic imp 1-3,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9740,Cysto impl 4 or more,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9741,Impl pressure sensor w/angio,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9742,Laryngoscopy with injection,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9743,Bulking/spacer material impl,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9744,Abd us w/contrast,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9745,Nasal endo eustachian tube,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9747,"Ablation, hifu, prostate",Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9749,Repair nasal stenosis w/imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9750,Ins/rem-replace compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9762,Cardiac mri seg dys strain,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9763,Cardiac mri seg dys stress,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9765,Revasc intra lithotrip-stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9767,Revasc lithotrip-stent-ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9768,Endo us-guide hep porto grad,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9769,Cysto w/temp pros implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9770,"Vitrec/mech pars, subret inj",Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9771,Nsl/sins cryo post nasal tis,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9772,Revasc lithotrip tibi/perone,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9773,Revasc lithotr-stent tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9774,Revasc lithotr-ather tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9775,Revasc lith-sten-ath tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,C9803,Hopd covid-19 spec collect,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0120,Periodic oral evaluation,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0140,Limit oral eval problm focus,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0145,"Oral evaluation, pt < 3yrs",Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0150,Comprehensve oral evaluation,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0160,Extensv oral eval prob focus,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0170,"Re-eval,est pt,problem focus",Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0171,Re-eval post-op visit,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0180,Comp periodontal evaluation,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0190,Screening of a patient,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0191,Assessment of a patient,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0210,Intraor complete film series,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0220,Intraoral periapical first,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0230,Intraoral periapical ea add,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0240,Intraoral occlusal film,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0250,Extraoral 2d project image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0251,Extraoral posterior image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0260,Extraoral ea additional film,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0270,Dental bitewing single image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0272,Dental bitewings two images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0273,Bitewings - three images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0274,Bitewings four images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0277,Vert bitewings 7 to 8 images,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0290,Skull/facial bone image,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0310,Dental saliography,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0320,Dental tmj arthrogram incl i,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0321,Other tmj images by report,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0322,Dental tomographic survey,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0330,Panoramic image,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0340,2d cephalometric image,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0350,Oral/facial photo images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0351,3d photographic image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0364,Cone beam ct capt & interp,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0365,Cone beam ct interprete man,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0366,Cone beam ct interprete max,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0367,Cone beam ct interp both jaw,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0368,Cone beam ct interprete tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0369,Max mri capture & interprete,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0370,Max ultrasound capt & interp,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0371,Sialoendoscopy capt & interp,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0380,Cone beam ct capture limited,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0381,Cone beam ct capt mandible,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0382,Cone beam ct capt maxilla,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0383,Cone beam ct both jaws,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0384,Cone beam ct capture tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0385,Max mri image capture,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0386,Max ultrasound image capture,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0391,Imterprete diagnostic image,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0393,Trtmnt simulation 3d image,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0394,Digital sub 2 or more images,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0395,Fusion 2 or more 3d images,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0411,Hba1c in office testing,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0412,Blood glucose level test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0414,Lab process microbial spec,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0415,Collection of microorganisms,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0416,Viral culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0418,Analysis of saliva sample,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0419,Assess of salivary flow,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0421,Gen tst suscept oral disease,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0422,Collect & prep genetic samp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0423,Genetic test spec analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0425,Caries susceptibility test,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0431,Diag tst detect mucos abnorm,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0460,Pulp vitality test,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0470,Diagnostic casts,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0472,"Gross exam, prep & report",Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0473,"Micro exam, prep & report",Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0474,Micro w exam of surg margins,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0475,Decalcification procedure,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0476,Spec stains for microorganis,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0477,Spec stains not for microorg,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0478,Immunohistochemical stains,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0479,Tissue in-situ hybridization,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0480,Cytopath smear prep & report,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0481,Electron microscopy,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0482,Direct immunofluorescence,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0483,Indirect immunofluorescence,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0484,Consult slides prep elsewher,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0485,Consult inc prep of slides,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0486,Access of transep cytol samp,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0502,Other oral pathology procedu,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0600,Non-ionizing diag proc,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0601,Caries risk assess low risk,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0602,Caries risk assess mod risk,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0603,Caries risk assess high risk,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0604,Antigen test pub hlth pathog,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0605,Antibody test pub hlth path,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0701,Pano radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0702,2d cephal radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0703,2d oral/facial photo image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0704,3d photo image capture only,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0705,Extra oral post radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0706,Intraoral occlus radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0707,Intraoral periap radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0708,Intraoral bite radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0709,Intraoral cmplt radio images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D0999,Unspecified diagnostic proce,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1110,Dental prophylaxis adult,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1120,Dental prophylaxis child,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1206,Topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1208,Topical app fluorid ex vrnsh,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1310,Nutri counsel-control caries,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1320,Tobacco counseling,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1321,Couns for high risk sub use,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1330,Oral hygiene instruction,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1351,Dental sealant per tooth,Dental,Per Unit,$24.50 ,OP,$24.50 ,$24.50 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1352,"Prev resin rest, perm tooth",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1353,Sealant repair per tooth,Dental,Per Unit,$24.50 ,OP,$24.50 ,$24.50 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1354,Int caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1355,Caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1510,Space maintainer fxd unilat,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1515,Fixed bilat space maintainer,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1516,"Fixed bilat space maint, max",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1517,"Fixed bilat space maint, man",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1520,Remove unilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1525,Remove bilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1526,"Remove bilat space main, max",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1527,"Remove bilat space main, man",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1550,Recement space maintainer,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1551,Recement space maint - max,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1552,Recement space maint - man,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1553,Recement unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1555,Remove fix space maintainer,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1556,Rem fixed unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1557,Remove fixed bilat maint max,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1558,Remove fixed bilat man,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1575,"Dist space maint, fixed unil",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D1999,Unspecified preventive proc,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2140,Amalgam one surface permanen,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2150,Amalgam two surfaces permane,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2160,Amalgam three surfaces perma,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2161,Amalgam 4 or > surfaces perm,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2330,Resin one surface-anterior,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2331,Resin two surfaces-anterior,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2332,Resin three surfaces-anterio,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2335,Resin 4/> surf or w incis an,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2390,Ant resin-based cmpst crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2391,Post 1 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2392,Post 2 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2393,Post 3 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2394,Post >=4srfc resinbase cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2410,Dental gold foil one surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2420,Dental gold foil two surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2430,Dental gold foil three surfa,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2510,Dental inlay metalic 1 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2520,Dental inlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2530,Dental inlay metl 3/more sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2542,Dental onlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2543,Dental onlay metallic 3 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2544,Dental onlay metl 4/more sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2610,Inlay porcelain/ceramic 1 su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2620,Inlay porcelain/ceramic 2 su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2630,Dental onlay porc 3/more sur,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2642,Dental onlay porcelin 2 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2643,Dental onlay porcelin 3 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2644,Dental onlay porc 4/more sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2650,Inlay composite/resin one su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2651,Inlay composite/resin two su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2652,Dental inlay resin 3/mre sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2662,Dental onlay resin 2 surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2663,Dental onlay resin 3 surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2664,Dental onlay resin 4/mre sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2710,Crown resin-based indirect,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2712,Crown 3/4 resin-based compos,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2720,Crown resin w/ high noble me,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2721,Crown resin w/ base metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2722,Crown resin w/ noble metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2740,Crown porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2750,Crown porcelain w/ h noble m,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2751,Crown porcelain fused base m,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2752,Crown porcelain w/ noble met,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2753,Crown porc fused to titanium,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2780,Crown 3/4 cast hi noble met,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2781,Crown 3/4 cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2782,Crown 3/4 cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2790,Crown full cast high noble m,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2791,Crown full cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2792,Crown full cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2794,Crown-titanium,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2799,Provisional crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2910,Recement inlay onlay or part,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2915,Recement cast or prefab post,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2920,Re-cement or re-bond crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2921,Reattach tooth fragment,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2928,Prefab porc/cer crown perm,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2929,Prefab porc/ceram crown pri,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2930,Prefab stnlss steel crwn pri,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2931,Prefab stnlss steel crown pe,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2932,Prefabricated resin crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2933,Prefab stainless steel crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2934,Prefab steel crown primary,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2941,Int therapeutic restoration,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2950,Core build-up incl any pins,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2951,Tooth pin retention,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2952,Post and core cast + crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2953,Each addtnl cast post,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2954,Prefab post/core + crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2955,Post removal,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2957,Each addtnl prefab post,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2960,Labial veneer resin direct,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2961,Labial veneer resin indirect,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2962,Labial veneer porc indirect,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2970,Temp crown (fractured tooth),Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2971,Add proc construct new crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2975,Coping,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2980,Crown repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2981,Inlay repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2982,Onlay repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2983,Veneer repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2990,Resin infiltration of lesion,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D2999,Dental unspec restorative pr,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3110,Pulp cap direct,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3120,Pulp cap indirect,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3220,Therapeutic pulpotomy,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3221,Gross pulpal debridement,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3222,Part pulp for apexogenesis,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3230,Pulpal therapy anterior prim,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3240,Pulpal therapy posterior pri,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3310,"End thxpy, anterior tooth",Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3320,"End thxpy, premolar tooth",Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3330,"End thxpy, molar tooth",Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3331,Non-surg tx root canal obs,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3332,Incomplete endodontic tx,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3333,Internal root repair,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3346,Retreat root canal anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3347,Retreat root canal premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3348,Retreat root canal molar,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3351,Apexification/recalc initial,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3352,Apexification/recalc interim,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3353,Apexification/recalc final,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3355,Pulpal regeneration initial,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3356,Pulpal regeneration interim,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3357,Pulpal regeneration complete,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3410,Apicoectomy - anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3421,Root surgery premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3425,Root surgery molar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3426,Root surgery ea add root,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3427,Periradicular surgery,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3428,Bone graft peri per tooth,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3429,Bone graft peri each addl,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3430,Retrograde filling,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3431,Biological materials,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3432,Guided tissue regeneration,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3450,Root amputation,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3460,Endodontic endosseous implan,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3470,Intentional replantation,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3471,Surg rep root res anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3472,Surg rep root res premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3473,Surg rep root res molar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3501,Surg exp root surf anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3502,Surg exp root surf premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3503,Surg exp root surf molar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3910,Isolation- tooth w rubb dam,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3920,Tooth splitting,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3950,Canal prep/fitting of dowel,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D3999,Endodontic procedure,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4210,Gingivectomy/plasty 4 or mor,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4211,Gingivectomy/plasty 1 to 3,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4212,Gingivectomy/plasty rest,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4230,Ana crown exp 4 or> per quad,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4231,Ana crown exp 1-3 per quad,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4240,Gingival flap proc w/ planin,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4241,Gngvl flap w rootplan 1-3 th,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4245,Apically positioned flap,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4249,Crown lengthen hard tissue,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4260,Osseous surgery 4 or more,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4261,Osseous surg 1 to 3 teeth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4263,Bone replce graft first site,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4264,Bone replce graft each add,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4265,Bio mtrls to aid soft/os reg,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4266,Guided tiss regen resorble,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4267,Guided tiss regen nonresorb,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4268,Surgical revision procedure,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4270,Pedicle soft tissue graft pr,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4273,Auto tissue graft 1st tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4274,Mesial/distal wedge proc,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4275,Non-auto graft 1st tooth,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4276,Con tissue w dble ped graft,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4277,Soft tissue graft firsttooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4278,Soft tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4283,Auto tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4285,Non-auto graft addl tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4320,Provision splnt intracoronal,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4321,Provisional splint extracoro,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4341,Periodontal scaling & root,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4342,Periodontal scaling 1-3teeth,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4346,Scaling gingiv inflammation,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4355,Full mouth debridement,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4381,Localized delivery antimicro,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4910,Periodontal maint procedures,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4920,Unscheduled dressing change,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4921,Gingival irrigation per quad,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D4999,Unspecified periodontal proc,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5110,Dentures complete maxillary,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5120,Dentures complete mandible,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5130,Dentures immediat maxillary,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5140,Dentures immediat mandible,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5211,Dentures maxill part resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5212,Dentures mand part resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5213,Dentures maxill part metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5214,Dentures mandibl part metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5221,Immed max part denture resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5222,Immed man part denture resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5223,Immed max part dent metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5224,Immed mand part dent metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5225,Maxillary part denture flex,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5226,Mandibular part denture flex,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5281,Removable partial denture,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5282,"Remove unil part denture,max",Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5283,"Remove unil part denture,man",Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5284,Rem unilat dent flex base,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5286,Rem unilat dent 1 pc resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5410,Dentures adjust cmplt maxil,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5411,Dentures adjust cmplt mand,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5421,Dentures adjust part maxill,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5422,Dentures adjust part mandbl,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5510,Dentur repr broken compl bas,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5511,Rep broke comp dent base man,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5512,Rep broke comp dent base max,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5520,Replace denture teeth complt,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5610,Dentures repair resin base,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5611,Rep resin part dent base man,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5612,Rep resin part dent base max,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5620,Rep part denture cast frame,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5621,Rep cast part frame man,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5622,Rep cast part frame max,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5630,Rep partial denture clasp,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5640,Replace part denture teeth,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5650,Add tooth to partial denture,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5660,Add clasp to partial denture,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5670,Replc tth&acrlc on mtl frmwk,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5671,Replc tth&acrlc mandibular,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5710,Dentures rebase cmplt maxil,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5711,Dentures rebase cmplt mand,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5720,Dentures rebase part maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5721,Dentures rebase part mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5730,Denture reln cmplt max dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5731,Denture reln cmplt mand dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5740,Denture reln part max dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5741,Denture reln part mand dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5750,Denture reln cmplt max indir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5751,Denture reln cmplt mand ind,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5760,Denture reln part max indir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5761,Denture reln part mand indir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5810,Denture interm cmplt maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5811,Denture interm cmplt mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5820,Denture interm part maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5821,Denture interm part mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5850,Denture tiss conditn maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5851,Denture tiss condtin mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5862,Precision attachment,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5863,Overdenture complete max,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5864,Overdenture partial max,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5865,Overdenture complete mandib,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5866,Overdenture partial mandib,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5867,Replacement of precision att,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5875,Prosthesis modification,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5876,Add metal sub to acrylc dent,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5899,Removable prosthodontic proc,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5911,Facial moulage sectional,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5912,Facial moulage complete,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5913,Nasal prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5914,Auricular prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5915,Orbital prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5916,Ocular prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5919,Facial prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5922,Nasal septal prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5923,Ocular prosthesis interim,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5924,Cranial prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5925,Facial augmentation implant,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5926,Replacement nasal prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5927,Auricular replacement,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5928,Orbital replacement,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5929,Facial replacement,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5931,Surgical obturator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5932,Postsurgical obturator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5933,Refitting of obturator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5934,Mandibular flange prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5935,Mandibular denture prosth,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5936,Temp obturator prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5937,Trismus appliance,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5951,Feeding aid,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5952,Pediatric speech aid,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5953,Adult speech aid,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5954,Superimposed prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5955,Palatal lift prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5958,Intraoral con def inter plt,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5959,Intraoral con def mod palat,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5960,Modify speech aid prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5982,Surgical stent,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5983,Radiation applicator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5984,Radiation shield,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5985,Radiation cone locator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5986,Fluoride applicator,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5987,Commissure splint,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5988,Surgical splint,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5991,Vesiculobullous disease carr,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5992,Adjust max prost appliance,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5993,Main/clean max prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5994,Peridontal medicament,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5995,"Peri medicament w/seal, max",Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5996,"Peri medicament w/seal, mand",Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D5999,Maxillofacial prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6010,Odontics endosteal implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6011,Second stage implant surgery,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6012,Endosteal implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6013,Surgical place mini implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6040,Odontics eposteal implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6050,Odontics transosteal implnt,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6051,Interim abutment,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6055,Implant connecting bar,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6056,Prefabricated abutment,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6057,Custom abutment,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6058,Abutment supported crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6059,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6060,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6061,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6062,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6063,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6064,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6065,Implant supported crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6066,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6067,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6068,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6069,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6070,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6071,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6072,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6073,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6074,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6075,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6076,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6077,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6080,Implant maintenance,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6081,"Scale & debride, single imp",Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6082,Imp crown porc to base alloy,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6083,Imp crown porc to noble allo,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6084,Imp crown porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6085,Provisional implant crown,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6086,Imp crown base alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6087,Implant crown noble alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6088,Imp crown titanium alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6090,Repair implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6091,Repl semi/precision attach,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6092,Recement supp crown,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6093,Recement supp part denture,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6094,Abut support crown titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6095,Odontics repr abutment,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6096,Remove broken imp ret screw,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6097,Abut crown porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6098,Imp retain porc to base allo,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6099,Imp retainer for fpd,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6100,Removal of implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6101,Debridement of a periimplant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6102,Debridement & contouring,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6103,Bone graft repair perimplant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6104,Bone graft time of implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6110,Implnt/abut remov dent max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6111,Implnt/abut remov dent mand,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6112,Imp/abut rem dent part max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6113,Imp/abut rem dent part mand,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6114,Implnt/abut fixed dent max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6115,Implnt/abut fixed dent mand,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6116,Imp/abut fixed dent part max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6117,Imp/abut fixed dent part man,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6118,Imp/abut int fixed dent man,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6119,Int/abut int fixed dent max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6120,Imp retain porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6121,Retain metal fpd base alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6122,Retain metal fpd noble alloy,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6123,Retain metal fpd titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6190,Radio/surgical implant index,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6191,Semi precision abutment,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6192,Semi precision attachment,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6194,Abut support retainer titani,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6195,Abut retain porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6199,Implant procedure,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6205,Pontic-indirect resin based,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6210,Prosthodont high noble metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6211,Bridge base metal cast,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6212,Bridge noble metal cast,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6214,Pontic titanium,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6240,Bridge porcelain high noble,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6241,Bridge porcelain base metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6242,Bridge porcelain nobel metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6243,Pontic porcelain to titanium,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6245,Bridge porcelain/ceramic,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6250,Bridge resin w/high noble,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6251,Bridge resin base metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6252,Bridge resin w/noble metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6253,Provisional pontic,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6545,Dental retainr cast metl,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6548,Porcelain/ceramic retainer,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6549,Resin retainer,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6600,Porcelain/ceramic inlay 2srf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6601,Porc/ceram inlay >= 3 surfac,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6602,Cst hgh nble mtl inlay 2 srf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6603,Cst hgh nble mtl inlay >=3sr,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6604,Cst bse mtl inlay 2 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6605,Cst bse mtl inlay >= 3 surfa,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6606,Cast noble metal inlay 2 sur,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6607,Cst noble mtl inlay >=3 surf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6608,Onlay porc/crmc 2 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6609,Onlay porc/crmc >=3 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6610,Onlay cst hgh nbl mtl 2 srfc,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6611,Onlay cst hgh nbl mtl >=3srf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6612,Onlay cst base mtl 2 surface,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6613,Onlay cst base mtl >=3 surfa,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6614,Onlay cst nbl mtl 2 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6615,Onlay cst nbl mtl >=3 surfac,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6624,Inlay titanium,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6634,Onlay titanium,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6710,Crown-indirect resin based,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6720,Retain crown resin w hi nble,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6721,Crown resin w/base metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6722,Crown resin w/noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6740,Crown porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6750,Crown porcelain high noble,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6751,Crown porcelain base metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6752,Crown porcelain noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6753,Retain crown porc to titaniu,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6780,Crown 3/4 high noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6781,Crown 3/4 cast based metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6782,Crown 3/4 cast noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6784,Retainer crown 3/4 titanium,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6790,Crown full high noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6791,Crown full base metal cast,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6792,Crown full noble metal cast,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6793,Provisional retainer crown,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6794,Crown titanium,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6920,Dental connector bar,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6930,Recement/bond part denture,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6940,Stress breaker,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6950,Precision attachment,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6980,Fixed partial repair,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6985,Pediatric partial denture fx,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D6999,Fixed prosthodontic proc,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7111,Extraction coronal remnants,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7140,Extraction erupted tooth/exr,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7210,Rem imp tooth w mucoper flp,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7220,Impact tooth remov soft tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7230,Impact tooth remov part bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7240,Impact tooth remov comp bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7241,Impact tooth rem bony w/comp,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7250,Tooth root removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7251,Coronectomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7260,Oral antral fistula closure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7261,Primary closure sinus perf,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7270,Tooth reimplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7272,Tooth transplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7280,Exposure of unerupted tooth,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7282,Mobilize erupted/malpos toot,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7283,Place device impacted tooth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7285,Biopsy of oral tissue hard,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7286,Biopsy of oral tissue soft,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7287,Exfoliative cytolog collect,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7288,Brush biopsy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7290,Repositioning of teeth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7291,Transseptal fiberotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7292,Screw retained plate,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7293,Temp anchorage dev w flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7294,Temp anchorage dev w/o flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7295,"Bone harvest,auto graft proc",Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7296,"Corticotomy, 1-3 teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7297,"Corticotomy, 4 or more teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7310,Alveoplasty w/ extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7311,Alveoloplasty w/extract 1-3,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7320,Alveoplasty w/o extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7321,Alveoloplasty not w/extracts,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7340,Vestibuloplasty ridge extens,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7350,Vestibuloplasty exten graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7410,Rad exc lesion up to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7411,Excision benign lesion>1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7412,Excision benign lesion compl,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7413,Excision malig lesion<=1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7414,Excision malig lesion>1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7415,Excision malig les complicat,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7440,Malig tumor exc to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7441,Malig tumor > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7450,Rem odontogen cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7451,Rem odontogen cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7460,Rem nonodonto cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7461,Rem nonodonto cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7465,Lesion destruction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7471,Rem exostosis any site,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7472,Removal of torus palatinus,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7473,Remove torus mandibularis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7485,Surg reduct osseoustuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7490,Maxilla or mandible resectio,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7510,I&d absc intraoral soft tiss,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7511,Incision/drain abscess intra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7520,I&d abscess extraoral,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7521,Incision/drain abscess extra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7530,Removal fb skin/areolar tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7540,Removal of fb reaction,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7550,Removal of sloughed off bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7560,Maxillary sinusotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7610,Maxilla open reduct simple,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7620,Clsd reduct simpl maxilla fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7630,Open red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7640,Clsd red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7650,Open red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7660,Clsd red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7670,Closd rductn splint alveolus,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7671,Alveolus open reduction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7680,Reduct simple facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7710,Maxilla open reduct compound,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7720,Clsd reduct compd maxilla fx,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7730,Open reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7740,Clsd reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7750,Open red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7760,Clsd red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7770,Open reduc compd alveolus fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7771,Alveolus clsd reduc stblz te,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7780,Reduct compnd facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7810,Tmj open reduct-dislocation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7820,Closed tmp manipulation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7830,Tmj manipulation under anest,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7840,Removal of tmj condyle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7850,Tmj meniscectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7852,Tmj repair of joint disc,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7854,Tmj excisn of joint membrane,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7856,Tmj cutting of a muscle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7858,Tmj reconstruction,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7860,Tmj cutting into joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7865,Tmj reshaping components,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7870,Tmj aspiration joint fluid,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7871,Lysis + lavage w catheters,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7872,Tmj diagnostic arthroscopy,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7873,Tmj arthroscopy lysis adhesn,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7874,Tmj arthroscopy disc reposit,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7875,Tmj arthroscopy synovectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7876,Tmj arthroscopy discectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7877,Tmj arthroscopy debridement,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7880,Occlusal orthotic appliance,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7881,Occ orthotic device adjust,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7899,Tmj unspecified therapy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7910,Dent sutur recent wnd to 5cm,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7911,Dental suture wound to 5 cm,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7912,Suture complicate wnd > 5 cm,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7920,Dental skin graft,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7921,Collect & appl blood product,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7922,Place intra-socket bio dress,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7940,Reshaping bone orthognathic,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7941,Bone cutting ramus closed,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7943,Cutting ramus open w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7944,Bone cutting segmented,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7945,Bone cutting body mandible,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7946,Reconstruction maxilla total,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7947,Reconstruct maxilla segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7948,Reconstruct midface no graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7949,Reconstruct midface w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7950,Mandible graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7951,Sinus aug w bone or bone sub,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7952,Sinus augmentation vertical,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7953,Bone replacement graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7955,Repair maxillofacial defects,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7960,Frenulectomy/frenectomy,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7961,Buccal/labial frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7962,Lingual frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7963,Frenuloplasty,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7970,Excision hyperplastic tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7971,Excision pericoronal gingiva,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7972,Surg redct fibrous tuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7979,Non-surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7980,Surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7981,Excision of salivary gland,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7982,Sialodochoplasty,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7983,Closure of salivary fistula,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7990,Emergency tracheotomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7991,Dental coronoidectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7993,Surg place craniofacial impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7994,Surg place zygomatic impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7995,Synthetic graft facial bones,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7996,Implant mandible for augment,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7997,Appliance removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7998,Intraoral place of fix dev,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D7999,Oral surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8010,Limited dental tx primary,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8020,Limited dental tx transition,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8030,Limited dental tx adolescent,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8040,Limited dental tx adult,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8050,Intercep dental tx primary,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8060,Intercep dental tx transitn,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8070,Compre dental tx transition,Dental,Per Unit,$195.04 ,OP,$195.04 ,$195.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8080,Compre dental tx adolescent,Dental,Per Unit,$195.04 ,OP,$195.04 ,$195.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8090,Compre dental tx adult,Dental,Per Unit,$195.04 ,OP,$195.04 ,$195.04 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8210,Orthodontic rem appliance tx,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8220,Fixed appliance therapy habt,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8660,Preorthodontic tx visit,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8670,Periodic orthodontc tx visit,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8680,Orthodontic retention,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8681,Removable retainer adjust,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8690,Orthodontic treatment,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8691,Repair ortho appliance,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8692,Replacement retainer,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8693,Rebond/recement retainers,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8694,Repair fixed retainers,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8695,Remove fixed ortho appliance,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8696,Rep of ortho appliance max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8697,Rep of ortho appliance man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8698,Recement fixed retainer max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8699,Recement fixed retainer man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8701,Repair fixed retainer max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8702,Repair of fixed retainer man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8703,Replace broken retainer max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8704,Replace broken retainer man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D8999,Orthodontic procedure,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9110,Tx dental pain minor proc,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9120,Fix partial denture section,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9130,Temporomandibular joint dysf,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9210,Dent anesthesia w/o surgery,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9211,Regional block anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9212,Trigeminal block anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9215,Local anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9219,Eval mod/deep sed/gen anest,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9220,General anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9221,General anesthesia ea ad 15m,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9222,"Deep anest, 1st 15 min",Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9223,General anesth ea addl 15 mi,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9230,Analgesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9239,"Iv mod sedation, 1st 15 min",Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9241,Intravenous sedation,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9242,Iv sedation ea ad 15 m,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9243,Iv sedation ea addl 15m,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9248,Sedation (non-iv),Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9310,Dental consultation,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9311,Consult w/med hlth care prof,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9410,Dental house call,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9420,Hospital/asc call,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9430,Office visit during hours,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9440,Office visit after hours,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9450,Case presentation tx plan,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9610,Dent therapeutic drug inject,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9612,Thera par drugs 2 or > admin,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9613,Infiltration thera drug,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9630,Drugs/meds disp for home use,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9910,Dent appl desensitizing med,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9911,Appl desensitizing resin,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9920,Behavior management,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9930,Treatment of complications,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9931,Clean/inspect rem appliance,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9932,Clean & inspect rem dent max,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9933,Clean & inspect rem dent man,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9934,Clean rem part denture max,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9935,Clean rem part denture mand,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9940,Dental occlusal guard,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9941,Fabrication athletic guard,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9942,Repair/reline occlusal guard,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9943,Occlusal guard adjustment,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9944,"Occ guard, hard, full arch",Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9945,"Occ guard, soft, full arch",Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9946,"Occ guard, hard, part arch",Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9950,Occlusion analysis,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9951,Limited occlusal adjustment,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9952,Complete occlusal adjustment,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9970,Enamel microabrasion,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9971,Odontoplasty per tooth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9972,Extrnl bleaching per arch,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9973,Extrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9974,Intrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9975,External bleaching home app,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9991,"Case mgmt, appt barriers",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9992,"Case mgmt, care coordination",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9993,"Case mgmt, interviewing",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9994,"Case mgmt, pt education",Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9995,Teledentistry real-time,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9996,Teledentistry dent review,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9997,Dent case mgmt special needs,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,D9999,Adjunctive procedure,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0008,Admin influenza virus vac,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0009,Admin pneumococcal vaccine,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0010,Admin hepatitis b vaccine,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0027,Semen analysis,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0068,Adm iv infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0069,Adm sq infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0070,Adm of chemo drug in home,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0071,Comm svcs by rhc/fqhc 5 min,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0076,Care manag h vst new pt 20 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0077,Care manag h vst new pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0078,Care manag h vst new pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0079,Care manag h vst new pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0080,Care manag h vst new pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0081,Care man h v ext pt 20 mi,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0082,Care man h v ext pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0083,Care man h v ext pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0084,Care man h v ext pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0085,Care man h v ext pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0086,Care man home care plan 30 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0087,Care man home care plan 60 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0088,Adm iv drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0089,Adm subq drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0090,Adm iv chemo 1st home visit,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0103,Psa screening,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0104,Ca screen;flexi sigmoidscope,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0105,Colorectal scrn; hi risk ind,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0108,Diab manage trn per indiv,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0109,Diab manage trn ind/group,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0117,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0118,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0121,Colon ca scrn not hi rsk ind,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0122,Colon ca scrn; barium enema,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0123,Screen cerv/vag thin layer,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0124,Screen c/v thin layer by md,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0127,Trim nail(s),General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0128,Corf skilled nursing service,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0130,Single energy x-ray study,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0141,"Scr c/v cyto,autosys and md",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0143,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0144,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0145,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0147,"Scr c/v cyto, automated sys",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0148,"Scr c/v cyto, autosys, rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0151,"Hhcp-serv of pt,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0152,"Hhcp-serv of ot,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0153,"Hhcp-svs of s/l path,ea 15mn",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0155,"Hhcp-svs of csw,ea 15 min",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0157,Hhc pt assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0158,Hhc ot assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0159,Hhc pt maint ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0160,Hhc occup therapy ea 15,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0161,Hhc slp ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0162,"Hhc rn e&m plan svs, 15 min",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0166,"Extrnl counterpulse, per tx",Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0175,"Opps service,sched team conf",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0176,Opps/php;activity therapy,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0177,Opps/php; train & educ serv,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0179,Md recertification hha pt,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0180,Md certification hha patient,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0181,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0182,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0186,"Dstry eye lesn,fdr vssl tech",Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0202,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0204,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0206,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0219,Pet img wholbod melano nonco,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0235,Pet not otherwise specified,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0237,Therapeutic procd strg endur,Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0238,"Oth resp proc, indiv",Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0239,"Oth resp proc, group",Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0248,Demonstrate use home inr mon,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0252,Pet imaging initial dx,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0255,Current percep threshold tst,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0257,Unsched dialysis esrd pt hos,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0270,Mnt subs tx for change dx,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0271,Group mnt 2 or more 30 mins,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0278,"Iliac art angio,cardiac cath",Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0279,"Tomosynthesis, mammo",Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0283,Elec stim other than wound,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0289,"Arthro, loose body + chondro",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0293,"Non-cov surg proc,clin trial",Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0297,Ldct for lung ca screen,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0306,Cbc/diffwbc w/o platelet,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0307,Cbc without platelet,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0328,Fecal blood scrn immunoassay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0339,"Robot lin-radsurg com, first",Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0340,Robt lin-radsurg fractx 2-5,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0365,Vessel mapping hemo access,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0378,Hospital observation per hr,Ancillary Services,Per Unit,$651.20 ,OP,$651.20 ,$651.20 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0389,Ultrasound exam aaa screen,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0396,Alcohol/subs interv 15-30mn,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0397,Alcohol/subs interv >30 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0403,Ekg for initial prevent exam,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0404,Ekg tracing for initial prev,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0405,Ekg interpret & report preve,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0409,Corf related serv 15 mins ea,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0410,Grp psych partial hosp 45-50,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0411,Inter active grp psych parti,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0412,Open tx iliac spine uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0413,Pelvic ring fracture uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0414,Pelvic ring fx treat int fix,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0415,Open tx post pelvic fxcture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0420,Ed svc ckd ind per session,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0421,Ed svc ckd grp per session,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0422,Intens cardiac rehab w/exerc,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0423,Intens cardiac rehab no exer,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0424,Pulmonary rehab w exer,Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0431,Drug screen multiple class,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0432,Eia hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0433,Elisa hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0434,Drug screen multi drug class,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0435,Oral hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0436,Tobacco-use counsel 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0437,Tobacco-use counsel>10min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0442,Annual alcohol screen 15 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0443,Brief alcohol misuse counsel,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0444,Depression screen annual,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0445,High inten beh couns std 30m,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0446,Intens behave ther cardio dx,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0447,Behavior counsel obesity 15m,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0448,Place perm pacing cardiovert,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0451,Devlopment test interpt&rep,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0452,Molecular pathology interpr,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0459,Telehealth inpt pharm mgmt,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0464,"Colorec CA scr, sto bas DNA",Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0472,Hep c screen high risk/other,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0473,Group behave couns 2-10,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0475,Hiv combination assay,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0476,Hpv combo assay ca screen,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0477,Drug test presump optical,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0478,Drug test presump opt inst,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0479,Drug test presump not opt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0480,Drug test def 1-7 classes,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0491,Dialysis acu kidney no esrd,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0492,Md/oth eval acut kid no esrd,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0495,Rn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0496,Lpn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0498,Chemo extend iv infus w/pump,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0499,Hepb screen high risk indiv,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0500,Mod sedat endo service >5yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0502,"Init psych care manag, 70min",Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0503,"Subseq psych care man,60mi",Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0504,Init/sub psych care add 30 m,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0506,Comp asses care plan ccm svc,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0507,Care manage serv minimum 20,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0511,Ccm/bhi by rhc/fqhc 20min mo,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0512,Cocm by rhc/fqhc 60 min mo,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0515,Cognitive skills development,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0516,"Insert drug del implant, >=4",General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0517,Remove drug implant,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0518,Remove w insert drug implant,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G0659,Drug test def simple all cl,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2000,Blinded conv. tx mdd clin tr,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2010,Remot image submit by pt,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2011,Alcohol/sub misuse assess,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2012,Brief check in by md/qhp,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2014,Post-d/c care plan overs 30m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2015,Post-d/c care plan overs 60m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2058,Ccm add 20min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2064,Md mang high risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2065,Clin mang h risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2066,Inter devc remote 30d,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2082,Visit esketamine 56m or less,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2083,"Visit esketamine, > 56m",Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2168,Svs by pt in home health,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2169,Svs by ot in home health,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2213,Initiat med assist tx in er,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2214,Init/sub psych care m 1st 30,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2250,"Remot img sub by pt, non e/m",Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2251,"Brief chkin, 5-10, non-e/m",Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G2252,"Brief chkin by md/qhp, 11-20",Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G3001,"Admin + supply, tositumomab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6001,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6002,Stereoscopic x-ray guidance,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6003,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6004,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6005,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6006,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6007,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6008,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6009,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6010,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6011,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6012,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6013,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6014,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6015,Radiation tx delivery imrt,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6016,Delivery comp imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6018,Ileoscopy w/stent,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6019,Colonoscopy lesion removal,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6020,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6021,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6022,Sigmoidoscopy w/ablate tumr,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6023,Sigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6024,Lesion removal colonoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6025,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6027,Anoscopy hra w/spec collect,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6028,Anoscopy hra w/biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6030,Assay of amitriptyline,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6031,Assay of benzodiazepines,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6032,Assay of desipramine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6034,Assay of doxepin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6035,Assay of gold,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6036,Assay of Imipramine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6037,Assay of nortiptyline,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6038,Assay of salicylate,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6039,Assay of acetaminophen,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6040,Assay of ethanol,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6041,Assay of urine alkaloids,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6042,Assay of amphetamines,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6043,Assay of barbiturates,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6044,Assay of cocaine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6045,Assay of dihydrocodeinone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6046,Assay of dihydromorphinone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6047,Assay of dihydrotestosterone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6048,Assay of dimethadione,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6049,Assay of Epiandrosterone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6050,Assay of Ethchlorvynol,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6051,Assay of flurazepam,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6052,Assay of meprobamate,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6053,Assay of methadone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6054,Assay of methsuximide,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6055,Assay of nicotine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6056,Assay of opiates,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6057,Assay of phenothiazine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G6058,Drug confirmation,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9012,Other specified case mgmt,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9016,Demo-smoking cessation coun,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9020,Rimantadine hcl 100mg oral,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9034,"Zanamivir, inh pwdr, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9035,"Oseltamivir phosp, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9143,Warfarin respon genetic test,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9147,Outpt iv insulin tx any mea,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9157,Transesoph doppl cardiac mon,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9187,Bpci home visit,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9477,Care coord at hospice,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9686,Nursing facility conference,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9873,1 em core session,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9874,4 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9875,9 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9876,2 em core ms mo 7-9 no wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9877,2 em core ms mo 10-12 no wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9878,2 em core ms mo 7-9 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9879,2 em core ms mo 10-12 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9880,Em 5 percent wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9881,Em 9 percent wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9882,2 em ongoing ms mo 13-15 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9883,2 em ongoing ms mo 16-18 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9884,2 em ongoing ms mo 19-21 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9885,2 em ongoing ms mo 22-24 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9890,Em bridge payment,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,G9987,Bpci advanced in home visit,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0001,Alcohol and/or drug assess,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0002,Alcohol and/or drug screenin,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0003,Alcohol and/or drug screenin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0004,Alcohol and/or drug services,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0005,Alcohol and/or drug services,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0006,Alcohol and/or drug services,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0007,Alcohol and/or drug services,Behavioral Health,Per Unit,$135.70 ,OP,$135.70 ,$135.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0014,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0015,Alcohol and/or drug services,Behavioral Health,Per Unit,$339.88 ,OP,$339.88 ,$339.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0020,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0022,Alcohol and/or drug interven,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0031,Mh health assess by non-md,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0032,Mh svc plan dev by non-md,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0033,Oral med adm direct observe,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0034,Med trng & support per 15min,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0035,Mh partial hosp tx under 24h,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0037,Comm psy sup tx pgm per diem,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0046,"Mental health service, nos",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0047,Alcohol/drug abuse svc nos,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0049,Alcohol/drug screening,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H0050,Alcohol/drug service 15 min,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H1002,Carecoordination prenatal,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H1003,Prenatal at risk education,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H1011,Family assessment,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2000,Comp multidisipln evaluation,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2001,Rehabilitation program 1/2 d,Behavioral Health,Per Unit,$166.94 ,OP,$166.94 ,$166.94 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2010,Comprehensive med svc 15 min,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2011,"Crisis interven svc, 15 min",Behavioral Health,Per Unit,$135.70 ,OP,$135.70 ,$135.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2012,"Behav hlth day treat, per hr",Behavioral Health,Per Unit,$276.34 ,OP,$276.34 ,$276.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2014,"Skills train and dev, 15 min",Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2017,"Psysoc rehab svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2018,"Psysoc rehab svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2019,"Ther behav svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2020,"Ther behav svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2027,"Psychoed svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2028,"Sex offend tx svc, 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2029,"Sex offend tx svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2032,"Activity therapy, per 15 min",Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2033,Multisys ther/juvenile 15min,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2035,"A/d tx program, per hour",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,H2036,"A/d tx program, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0121,"Inj., omadacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0122,"Inj., eravacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0129,Abatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0130,Abciximab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0135,Adalimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0178,Aflibercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0179,"Inj, brolucizumab-dbll, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0180,Agalsidase beta injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0185,"Inj., aprepitant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0202,"Injection, alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0205,Alglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0207,Amifostine,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0210,Methyldopate hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0215,Alefacept,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0220,Alglucosidase alfa injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0221,Lumizyme injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0222,"Inj., patisiran, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0223,Inj givosiran 0.5 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0256,Alpha 1 proteinase inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0257,Glassia injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0287,Amphotericin b lipid complex,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0288,Ampho b cholesteryl sulfate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0289,Amphotericin b liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0291,"Inj., plazomicin, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0348,Anidulafungin injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0350,Injection anistreplase 30 u,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0364,Apomorphine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0365,"Aprotonin, 10,000 kiu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0401,Inj aripiprazole ext rel 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0475,Baclofen 10 mg injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0480,Basiliximab,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0485,Belatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0490,Belimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0517,"Inj., benralizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0558,Peng benzathine/procaine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0561,Penicillin g benzathine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0565,"Inj, bezlotoxumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0567,"Inj., cerliponase alfa 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0570,Buprenorphine implant 74.2mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0583,Bivalirudin,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0584,"Injection, burosumab-twza 1m",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0585,"Injection,onabotulinumtoxina",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0586,Abobotulinumtoxina,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0587,"Inj, rimabotulinumtoxinb",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0588,Incobotulinumtoxin a,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0591,"Inj deoxycholic acid, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0593,"Inj., lanadelumab-flyo, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0594,Busulfan injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0596,"Injection, ruconest",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0597,"C-1 esterase, berinert",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0598,"C-1 esterase, cinryze",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0599,"Inj., haegarda 10 units",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0600,Edetate calcium disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0604,"Cinacalcet, esrd on dialysis",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0606,"Inj, etelcalcetide, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0630,Calcitonin salmon injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0637,Caspofungin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0638,Canakinumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0641,Inj levoleucovorin nos 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0642,"Injection, khapzory, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0691,Inj lefamulin 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0693,"Inj., cefiderocol, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0695,Inj ceftolozane tazobactam,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0712,Ceftaroline fosamil inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0714,Ceftazidime and avibactam,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0716,Centruroides immune f(ab),Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0717,Certolizumab pegol inj 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0740,Cidofovir injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0775,"Collagenase, clost hist inj",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0791,Inj crizanlizumab-tmca 5mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0795,Corticorelin ovine triflutal,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0800,Corticotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0833,Cosyntropin injection nos,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0840,Crotalidae poly immune fab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0841,Inj crotalidae im f(ab')2 eq,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0850,Cytomegalovirus imm iv /vial,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0875,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0878,Daptomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0881,"Darbepoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0882,"Darbepoetin alfa, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0883,Argatroban nonesrd use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0884,Argatroban esrd dialysis 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0885,"Epoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0886,Epoetin alfa 1000 units esrd,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0890,Peginesatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0894,Decitabine injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0896,Inj luspatercept-aamt 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J0897,Denosumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1095,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1096,Dexametha opth insert 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1097,Phenylep ketorolac opth soln,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1162,Digoxin immune fab (ovine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1190,Dexrazoxane hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1201,Inj. cetirizine hcl 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1205,Chlorothiazide sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1267,Doripenem injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1290,Ecallantide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1300,Eculizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1301,"Injection, edaravone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1303,"Inj., ravulizumab-cwvz 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1322,"Elosulfase alfa, injection",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1327,Eptifibatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1410,Inj estrogen conjugate 25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1428,"Inj, eteplirsen, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1429,Inj golodirsen 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1430,Ethanolamine oleate 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1436,Etidronate disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1437,Inj. fe derisomaltose 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1438,Etanercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1439,Inj ferric carboxymaltos 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1442,Inj filgrastim excl biosimil,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1446,"Inj, tbo-filgrastim, 5 mcg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1447,Inj tbo filgrastim 1 microg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1451,"Fomepizole, 15 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1452,Intraocular fomivirsen na,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1453,Fosaprepitant injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1454,"Inj fosnetupitant, palonoset",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1455,Foscarnet sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1457,Gallium nitrate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1458,Galsulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1459,Inj ivig privigen 500 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1460,Gamma globulin 1 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1555,"Inj cuvitru, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1556,"Inj, imm glob bivigam, 500mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1557,Gammaplex injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1558,"Inj. xembify, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1559,Hizentra injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1560,Gamma globulin > 10 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1561,Gamunex-c/gammaked,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1562,"Vivaglobin, inj",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1566,"Immune globulin, powder",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1568,Octagam injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1569,Gammagard liquid injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1570,Ganciclovir sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1571,Hepagam b im injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1572,Flebogamma injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1573,"Hepagam b intravenous, inj",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1575,Hyqvia 100mg immuneglobulin,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1595,Injection glatiramer acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1599,"Ivig non-lyophilized, nos",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1602,Golimumab for iv use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1610,Glucagon hydrochloride/1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1628,"Inj., guselkumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1632,"Inj., brexanolone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1640,"Hemin, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1670,Tetanus immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1675,Histrelin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1738,Inj. meloxicam 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1740,Ibandronate sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1742,Ibutilide fumarate injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1743,Idursulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1744,Icatibant injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1745,Infliximab not biosimil 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1746,"Inj., ibalizumab-uiyk, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1750,Inj iron dextran,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1756,Iron sucrose injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1786,Imuglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1823,"Inj. inebilizumab-cdon, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1826,Interferon beta-1a inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1830,Interferon beta-1b / .25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1833,"Injection, isavuconazonium",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1930,Lanreotide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1931,Laronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1942,Aripiprazole lauroxil 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1943,"Inj., aristada initio, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1944,Aripirazole lauroxil 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1945,Lepirudin,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J1950,Leuprolide acetate /3.75 mg,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2062,Loxapine for inhalation 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2170,Mecasermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2182,"Injection, mepolizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2186,"Inj., meropenem, vaborbactam",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2248,Micafungin sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2278,Ziconotide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2315,"Naltrexone, depot form",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2323,Natalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2325,Nesiritide injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2326,"Inj, nusinersen, 0.1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2350,"Injection, ocrelizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2353,"Octreotide injection, depot",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2355,Oprelvekin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2357,Omalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2407,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2425,Palifermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2426,Paliperidone palmitate inj,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2469,Palonosetron hcl,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2502,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2503,Pegaptanib sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2504,"Pegademase bovine, 25 iu",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2505,"Injection, pegfilgrastim 6mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2507,Pegloticase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2513,Pentastarch 10% solution,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2515,Pentobarbital sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2545,Pentamidine non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2547,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2562,Plerixafor injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2597,Inj desmopressin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2724,Protein c concentrate,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2730,Pralidoxime chloride inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2770,Quinupristin/dalfopristin,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2778,Ranibizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2783,Rasburicase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2786,"Injection, reslizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2790,Rho d immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2791,Rhophylac injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2792,"Rho(d) immune globulin h, sd",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2793,Rilonacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2794,"Inj risperdal consta, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2796,Romiplostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2797,"Inj., rolapitant, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2798,"Inj., perseris, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2805,Sincalide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2820,Sargramostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2840,Inj sebelipase alfa 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2850,Inj secretin synthetic human,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2860,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2993,Reteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J2997,Alteplase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3031,"Inj., fremanezumab-vfrm 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3060,"Inj, taliglucerase alfa 10 u",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3090,Inj tedizolid phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3095,Telavancin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3101,Tenecteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3110,Teriparatide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3111,Inj. romosozumab-aqqg 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3145,Testosterone undecanoate 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3240,Thyrotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3241,Inj. teprotumumab-trbw 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3243,Tigecycline injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3245,"Inj., tildrakizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3246,Tirofiban hcl,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3262,Tocilizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3285,Treprostinil injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3300,Triamcinolone a inj prs-free,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3304,Inj triamcinolone ace xr 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3315,Triptorelin pamoate,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3316,"Inj., triptorelin xr 3.75 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3355,"Urofollitropin, 75 iu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3357,"Ustekinumab sub cu inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3358,"Ustekinumab, iv inject, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3365,"Urokinase 250,000 iu inj",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3380,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3385,Velaglucerase alfa,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3396,Verteporfin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3397,"Inj., vestronidase alfa-vjbk",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3398,Inj luxturna 1 billion vec g,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3399,Inj onase abepar-xioi treat,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3470,Hyaluronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3471,"Ovine, up to 999 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3472,"Ovine, 1000 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J3473,Hyaluronidase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7169,"Inj andexxa, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7170,"Inj., emicizumab-kxwh 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7175,"Inj, factor x, (human), 1iu",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7177,"Inj., fibryga, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7178,Inj human fibrinogen con nos,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7179,Vonvendi inj 1 iu vwf:rco,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7180,Factor xiii anti-hem factor,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7181,Factor xiii recomb a-subunit,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7182,Factor viii recomb novoeight,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7183,Wilate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7185,Xyntha inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7186,Antihemophilic viii/vwf comp,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7187,"Humate-p, inj",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7188,Factor viii recomb obizur,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7189,Factor viia recomb novoseven,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7190,Factor viii,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7191,Factor viii (porcine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7192,Factor viii recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7193,Factor ix non-recombinant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7194,Factor ix complex,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7195,Factor ix recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7196,Antithrombin recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7197,Antithrombin iii injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7198,Anti-inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7199,Hemophilia clot factor noc,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7200,Factor ix recombinan rixubis,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7201,Factor ix alprolix recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7202,Factor ix idelvion inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7203,Factor ix recomb gly rebinyn,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7204,Inj recombin esperoct per iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7205,Factor viii fc fusion recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7207,Factor viii pegylated recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7208,Inj. jivi 1 iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7209,Factor viii nuwiq recomb 1iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7210,"Inj, afstyla, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7211,"Inj, kovaltry, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7212,Factor viia recomb sevenfact,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7296,"Kyleena, 19.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7297,"Liletta, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7298,"Mirena, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7300,Intraut copper contraceptive,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7301,"Skyla, 13.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7302,Levonorgestrel iu 52 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7303,Contraceptive vaginal ring,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7304,Contraceptive hormone patch,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7306,Levonorgestrel implant sys,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7307,Etonogestrel implant system,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7308,Aminolevulinic acid hcl top,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7309,"Methyl aminolevulinate, top",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7310,Ganciclovir long act implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7311,"Inj., retisert, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7312,Dexamethasone intra implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7313,"Inj., iluvien, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7314,"Inj., yutiq, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7315,Ophthalmic mitomycin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7316,"Inj, ocriplasmin, 0.125 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7318,"Inj, durolane 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7320,"Genvisc 850, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7321,Hyalgan or supartz inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7322,Hymovis injection 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7323,Euflexxa inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7324,Orthovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7325,Synvisc or synvisc-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7326,Gel-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7327,Monovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7328,Gelsyn-3 injection 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7329,"Inj, trivisc 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7330,Cultured chondrocytes implnt,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7331,"Synojoynt, inj., 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7332,"Inj., triluron, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7333,Visco-3 inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7336,Capsaicin 8% patch,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7340,Carbidopa levodopa ent 100ml,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7345,"Aminolevulinic acid, 10% gel",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7351,Inj bimatoprost itc imp1mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7352,"Afamelanotide implant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7401,Mometasone furoate sinus imp,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7501,Azathioprine parenteral,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7504,Lymphocyte immune globulin,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7505,Monoclonal antibodies,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7511,Antithymocyte globuln rabbit,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7513,"Daclizumab, parenteral",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7525,Tacrolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7639,Dornase alfa non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7685,Tobramycin comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J7686,"Treprostinil, non-comp unit",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J8501,Oral aprepitant,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J8560,Etoposide oral 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J8562,Oral fludarabine phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J8565,Gefitinib oral,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J8655,"Oral netupitant, palonosetro",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J8670,"Rolapitant, oral, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J8705,Topotecan oral,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9010,Alemtuzumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9015,Aldesleukin injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9017,Arsenic trioxide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9019,Erwinaze injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9020,"Asparaginase, nos",Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9022,"Inj, atezolizumab,10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9023,"Injection, avelumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9025,Azacitidine injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9027,Clofarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9030,Bcg live intravesical 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9031,Bcg live intravesical vac,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9032,"Injection, belinostat, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9033,"Inj., treanda 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9034,"Inj., bendeka 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9035,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9036,Inj. belrapzo/bendamustine,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9039,"Injection, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9040,Bleomycin sulfate injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9041,"Inj., velcade 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9042,Brentuximab vedotin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9043,Cabazitaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9044,"Inj, bortezomib, nos, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9047,"Injection, carfilzomib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9050,Carmustine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9055,Cetuximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9057,"Inj., copanlisib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9065,Inj cladribine per 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9070,Cyclophosphamide 100 mg inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9098,Cytarabine liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9118,Inj. calaspargase pegol-mknl,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9119,"Inj., cemiplimab-rwlc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9120,Dactinomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9144,"Daratumumab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9145,"Injection, daratumumab 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9150,Daunorubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9151,Daunorubicin citrate inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9153,"Inj daunorubicin, cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9155,Degarelix injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9160,Denileukin diftitox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9171,Docetaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9173,"Inj., durvalumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9176,"Injection, elotuzumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9179,Eribulin mesylate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9185,Fludarabine phosphate inj,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9198,"Inj. infugem, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9199,"Injection, infugem, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9200,Floxuridine injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9202,Goserelin acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9204,"Inj mogamulizumab-kpkc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9205,Inj irinotecan liposome 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9207,Ixabepilone injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9208,Ifosfamide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9210,"Inj., emapalumab-lzsg, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9211,Idarubicin hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9213,Interferon alfa-2a inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9214,Interferon alfa-2b inj,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9216,Interferon gamma 1-b inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9217,Leuprolide acetate suspnsion,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9219,Leuprolide acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9223,"Inj. lurbinectedin, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9225,Vantas implant,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9226,Supprelin la implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9227,Inj. isatuximab-irfc 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9228,Ipilimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9230,Mechlorethamine hcl inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9245,Inj melpha hydroch nos 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9246,"Inj., evomela, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9261,Nelarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9262,"Inj, omacetaxine mep, 0.01mg",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9264,Paclitaxel protein bound,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9266,Pegaspargase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9268,Pentostatin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9270,Plicamycin (mithramycin) inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9271,Inj pembrolizumab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9280,Mitomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9281,Mitomycin instillation,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9285,"Inj, olaratumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9293,Mitoxantrone hydrochl / 5 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9295,"Injection, necitumumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9299,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9300,Gemtuzumab ozogamicin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9301,Obinutuzumab inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9302,Ofatumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9303,Panitumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9304,"Inj. pemetrexed, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9305,Inj. pemetrexed nos 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9306,"Injection, pertuzumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9307,Pralatrexate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9308,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9309,"Inj, polatuzumab vedotin 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9310,Rituximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9311,"Inj rituximab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9312,"Inj., rituximab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9313,"Inj., lumoxiti, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9315,Romidepsin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9316,"Pertuzu, trastuzu, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9317,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9320,Streptozocin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9325,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9328,Temozolomide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9330,Temsirolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9340,Thiotepa injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9352,Injection trabectedin 0.1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9354,"Inj, ado-trastuzumab emt 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9355,Inj trastuzumab excl biosimi,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9356,"Inj. herceptin hylecta, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9357,Valrubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9358,Inj fam-trastu deru-nxki 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9371,"Inj, vincristine sul lip 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9395,"Injection, fulvestrant",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9400,"Inj, ziv-aflibercept, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,J9600,Porfimer sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,L8604,Dextranomer/hyaluronic acid,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,L8605,Inj bulking agent anal canal,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,L8607,Inj vocal cord bulking agent,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,M0239,Bamlanivimab-xxxx infusion,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,M0243,Casirivi and imdevi infusion,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P2028,Cephalin floculation test,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P2029,Congo red blood test,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P2031,Hair analysis,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P2033,Blood thymol turbidity,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P2038,Blood mucoprotein,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P3000,Screen pap by tech w md supv,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P3001,Screening pap smear by phys,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P7001,Culture bacterial urine,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9010,Whole blood for transfusion,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9011,Blood split unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9012,Cryoprecipitate each unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9016,Rbc leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9017,Plasma 1 donor frz w/in 8 hr,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9019,"Platelets, each unit",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9020,Plaelet rich plasma unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9021,Red blood cells unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9022,Washed red blood cells unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9023,"Frozen plasma, pooled, sd",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9031,Platelets leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9032,"Platelets, irradiated",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9033,Platelets leukoreduced irrad,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9034,"Platelets, pheresis",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9035,Platelet pheres leukoreduced,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9036,Platelet pheresis irradiated,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9037,Plate pheres leukoredu irrad,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9038,Rbc irradiated,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9039,Rbc deglycerolized,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9040,Rbc leukoreduced irradiated,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9041,"Albumin (human),5%, 50ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9043,"Plasma protein fract,5%,50ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9044,Cryoprecipitatereducedplasma,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9045,"Albumin (human), 5%, 250 ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9046,"Albumin (human), 25%, 20 ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9047,"Albumin (human), 25%, 50ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9048,"Plasmaprotein fract,5%,250ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9050,"Granulocytes, pheresis unit",Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9051,"Blood, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9052,"Platelets, hla-m, l/r, unit",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9053,"Plt, pher, l/r cmv-neg, irr",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9054,"Blood, l/r, froz/degly/wash",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9055,"Plt, aph/pher, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9056,"Blood, l/r, irradiated",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9057,"Rbc, frz/deg/wsh, l/r, irrad",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9058,"Rbc, l/r, cmv-neg, irrad",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9059,"Plasma, frz between 8-24hour",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9060,Fr frz plasma donor retested,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9070,Pathogen reduced plasma pool,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9071,Pathogen reduced plasma sing,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9072,Plate path red/rapid bac tes,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9073,Platelets pheresis path redu,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9099,Blood component/product noc,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,P9100,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0035,Cardiokymography,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0081,Infusion ther other than che,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0084,Chemotherapy by infusion,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0085,Chemo by both infusion and o,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0091,Obtaining screen pap smear,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0111,Wet mounts/ w preparations,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0112,Potassium hydroxide preps,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0113,Pinworm examinations,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0114,Fern test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0115,Post-coital mucous exam,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0138,"Ferumoxytol, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0139,"Ferumoxytol, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0239,Bamlanivimab-xxxx,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0243,Casirivimab and imdevimab,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q0515,Sermorelin acetate injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2017,"Teniposide, 50 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2028,"Inj, sculptra, 0.5mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2034,Agriflu vaccine,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2035,"Afluria vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2036,"Flulaval vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2037,"Fluvirin vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2038,"Fluzone vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2039,"Influenza virus vaccine, nos",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2040,Tisagenlecleucel car-pos t,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2043,Sipuleucel-t auto cd54+,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2049,Imported lipodox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q2050,Doxorubicin inj 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q3014,Telehealth facility fee,Ancillary Services,Per Unit,$8.33 ,OP,$8.33 ,$8.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q3027,Inj beta interferon im 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q3028,Inj beta interferon sq 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4074,Iloprost non-comp unit dose,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4081,"Epoetin alfa, 100 units esrd",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4100,"Skin substitute, nos",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4101,Apligraf,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4102,Oasis wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4103,Oasis burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4104,Integra bmwd,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4105,Integra drt or omnigraft,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4106,Dermagraft,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4107,Graftjacket,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4108,Integra matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4110,Primatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4111,Gammagraft,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4112,Cymetra injectable,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4113,Graftjacket xpress,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4114,Integra flowable wound matri,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4115,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4116,Alloderm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4117,Hyalomatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4118,Matristem micromatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4119,Matristem wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4120,Matristem burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4121,Theraskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4122,"Dermacell, awm, porous sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4123,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4124,Oasis tri-layer wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4125,Arthroflex,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4126,Memoderm/derma/tranz/integup,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4127,Talymed,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4128,Flexhd/allopatchhd/matrixhd,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4129,Unite biomatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4130,Strattice tm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4131,Epifix or epicord,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4132,"Grafix core, grafixpl core",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4133,Grafix stravix prime pl sqcm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4134,Hmatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4135,Mediskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4136,Ezderm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4137,Amnioexcel biodexcel 1sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4138,"Biodfence dryflex, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4139,"Amnio or biodmatrix, inj 1cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4140,Biodfence 1cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4141,"Alloskin ac, 1 cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4142,Xcm biologic tiss matrix 1cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4143,"Repriza, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4145,"Epifix, inj, 1mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4146,"Tensix, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4147,Architect ecm px fx 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4148,Neox neox rt or clarix cord,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4149,"Excellagen, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4150,Allowrap ds or dry 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4151,"Amnioband, guardian 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4152,Dermapure 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4153,"Dermavest, plurivest sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4154,Biovance 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4155,Neoxflo or clarixflo 1 mg,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4156,Neox 100 or clarix 100,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4157,Revitalon 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4158,"Kerecis omega3, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4159,Affinity1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4160,Nushield 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4161,Bio-connekt per square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4162,"Wndex flw, bioskn flw, 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4163,"Woundex, bioskin, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4164,"Helicoll, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4165,"Keramatrix, kerasorb sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4166,"Cytal, per square centimeter",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4167,"Truskin, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4168,"Amnioband, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4169,"Artacent wound, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4170,"Cygnus, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4171,"Interfyl, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4172,Puraply or puraply am,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4173,Palingen or palingen xplus,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4174,Palingen or promatrx,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4175,Miroderm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4176,"Neopatch or therion, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4177,"Floweramnioflo, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4178,"Floweramniopatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4179,"Flowerderm, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4180,"Revita, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4181,"Amnio wound, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4182,"Transcyte, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4183,"Surgigraft, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4184,Cellesta or duo per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4185,Cellesta flowab amnion 0.5cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4186,Epifix 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4187,Epicord 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4188,Amnioarmor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4189,"Artacent ac, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4190,Artacent ac 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4191,Restorigin 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4192,"Restorigin, 1 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4193,Coll-e-derm 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4194,Novachor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4195,Puraply 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4196,Puraply am 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4197,Puraply xt 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4198,Genesis amnio membrane 1sqcm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4200,Skin te 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4201,Matrion 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4202,"Keroxx (2.5g/cc), 1cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4203,"Derma-gide, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4204,Xwrap 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4205,Membrane graft or wrap sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4206,Fluid flow or fluid gf 1 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4208,Novafix per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4209,Surgraft per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4210,Axolotl graf dualgraf sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4211,Amnion bio or axobio sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4212,"Allogen, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4213,"Ascent, 0.5 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4214,Cellesta cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4215,"Axolotl ambient, cryo 0.1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4216,Artacent cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4217,Woundfix biowound plus xplus,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4218,Surgicord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4219,Surgigraft dual per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4220,"Bellacell hd, surederm sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4221,Amniowrap2 per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4222,"Progenamatrix, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4226,Myown harv prep proc sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4227,Amniocore per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4228,"Bionextpatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4229,Cogenex amnio memb per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4230,Cogenex flow amnion 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4231,"Corplex p, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4232,"Corplex, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4233,Surfactor /nudyn per 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4234,"Xcellerate, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4235,Amniorepair or altiply sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4236,Carepatch per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4237,"Cryo-cord, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4238,"Derm-maxx, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4239,Amnio-maxx or lite per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4240,Corecyte topical only 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4241,"Polycyte, topical only 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4242,"Amniocyte plus, per 0.5 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4244,"Procenta, per 200 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4245,"Amniotext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4246,"Coretext or protext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4247,"Amniotext patch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4248,Dermacyte amn mem allo sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4249,"Amniply, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4250,Amnioamp-mp per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4254,Novafix dl per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q4255,"Reguard, topical use per sq",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5101,"Injection, zarxio",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5102,"Inj., infliximab biosimilar",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5103,"Injection, inflectra",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5104,"Injection, renflexis",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5105,Inj retacrit esrd on dialysi,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5106,Inj retacrit non-esrd use,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5107,Inj mvasi 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5108,"Injection, fulphila",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5109,"Injection, ixifi, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5110,Nivestym,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5111,"Injection, udenyca 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5112,Inj ontruzant 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5113,Inj herzuma 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5114,Inj ogivri 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5115,Inj truxima 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5116,"Inj., trazimera, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5117,"Inj., kanjinti, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5118,"Inj., zirabev, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5119,"Inj ruxience, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5121,"Inj. avsola, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q5122,"Inj, nyvepria",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9975,Factor VIII FC Fusion Recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9979,"Injection, Alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9980,"Genvisc, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9984,Kyleena,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9987,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9988,Platelet pheresis path reduc,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9989,"Ustekinumab IV Inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9991,Buprenorph xr 100 mg or less,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9992,Buprenorphine xr over 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9993,"Inj., triamcinolone ext rel",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,Q9995,"inj. emicizumab-kxwh, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0013,"Esketamine, nasal spray",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0040,"Injection, ticarcillin disod",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0088,Imatinib 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0126,Inj follitropin alfa 75 iu,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0132,Inj ganirelix acetat 250 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0140,"Saquinavir, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0142,Colistimethate inh sol mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0145,Peg interferon alfa-2a/180,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0148,Peg interferon alfa-2b/10,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0155,Epoprostenol dilutant,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0166,Inj olanzapine 2.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0175,Flutamide 125 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0178,Lomustine 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0190,"Mifepristone, oral, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0195,Pneumo vaccine 5-9 yrs,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0199,Med abortion inc all ex drug,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0201,Partial hospitalization serv,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0220,Medical conference by physic,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0221,"Medical conference, 60 min",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0250,Comp geriatr assmt team,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0257,End of life counseling,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0271,Home hospice case 30 days,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0280,"Medical home, initial plan",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0281,"Medical home, maintenance",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0311,Comp mgmt care coord adv ill,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0315,Disease management program,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0316,Follow-up/reassessment,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0340,Lifestyle mod 1st stage,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0353,Cancer treatmentplan initial,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0354,Cancer treatment plan change,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0390,Rout foot care per visit,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0395,Impression casting ft,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0592,Comp cont lens eval,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0601,Screening proctoscopy,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0618,Audiometry for hearing aid,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0800,Laser in situ keratomileusis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0810,Photorefractive keratectomy,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S0812,Phototherap keratect,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2066,Breast gap flap reconst,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2067,"Breast ""stacked"" diep/gap",General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2068,Breast diep or siea flap,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2083,Adjustment gastric band,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2112,Knee arthroscp harv,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2202,Echosclerotherapy,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2225,Myringotomy laser-assist,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2230,Implant semi-imp hear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2235,Implant auditory brain imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2260,Induced abortion 17-24 weeks,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2265,Induced abortion 25-28 wks,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2266,Induced abortion 29-31 wks,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2267,Induced abortion 32 or more,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2300,"Arthroscopy, shoulder, surgi",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2340,Chemodenervation of abductor,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2341,Chemodenerv adduct vocal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2342,Nasal endoscop po debrid,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2400,Fetal surg congen hernia,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2401,Fetal surg urin trac obstr,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2402,Fetal surg cong cyst malf,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2403,Fetal surg pulmon sequest,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2404,Fetal surg myelomeningo,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2405,Fetal surg sacrococ teratoma,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2409,Fetal surg noc,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S2411,Fetoscop laser ther ttts,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3620,Newborn metabolic screening,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3630,Eosinophil blood count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3645,Hiv-1 antibody testing of or,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3650,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3652,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3655,Antisperm antibodies test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3708,Gastrointestinal fat absorpt,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3721,Pca3 testing,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3722,Dose optimization auc - 5fu,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3800,Genetic testing als,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3840,Dna analysis ret-oncogene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3841,Gene test retinoblastoma,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3842,Gene test hippel-lindau,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3844,Dna analysis deafness,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3845,Gene test alpha-thalassemia,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3846,Gene test beta-thalassemia,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3849,Gene test niemann-pick,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3850,Gene test sickle cell,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3852,Dna analysis apoe alzheimer,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3853,Gene test myo musclr dyst,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3854,Gene profile panel breast,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3861,Genetic test brugada,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3865,Comp genet test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3866,Spec gene test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3870,Cgh test developmental delay,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3890,Fecal dna analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3900,Surface emg,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3902,Ballistocardiogram,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S3904,Masters two step,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4011,Ivf package,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4013,Compl gift case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4014,Compl zift case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4015,Complete ivf nos case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4016,Frozen ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4017,Ivf canc a stim case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4018,F emb trns canc case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4020,Ivf canc a aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4021,Ivf canc p aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4022,Asst oocyte fert case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4023,Incompl donor egg case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4025,Donor serv ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4026,Procure donor sperm,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4027,Store prev froz embryos,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4028,Microsurg epi sperm asp,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4030,Sperm procure init visit,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4031,Sperm procure subs visit,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4035,Stimulated iui case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4037,Cryo embryo transf case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4040,Monit store cryo embryo 30 d,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4042,Ovulation mgmt per cycle,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4981,Insert levonorgestrel ius,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S4989,Contracept iud,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S5180,Hh respiratory thrpy in eval,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S5181,Hh respiratory thrpy nos/day,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8032,Low dose CT lung screening,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8035,Magnetic source imaging,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8037,Mrcp,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8055,Us guidance fetal reduct,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8080,Scintimammography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8092,Electron beam computed tomog,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8110,Peak expiratory flow rate (p,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8930,Auricular electrostimulation,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8940,Hippotherapy per session,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8948,Low-level laser trmt 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8950,"Complex lymphedema therapy,",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S8990,Pt or manip for maint,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9015,Automated eeg monitoring,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9024,Paranasal sinus ultrasound,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9061,Medical supplies and equipme,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9090,Vertebral axial decompressio,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9098,Home phototherapy visit,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9128,"Speech therapy, in the home,",Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9129,"Occupational therapy, in the",Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9131,Pt in the home per diem,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9140,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9141,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9145,Insulin pump initiation,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9152,"Speech therapy, re-eval",Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9211,Home mgmt gest hypertension,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9213,Hm preeclamp per diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9214,Hm gest dm per diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9335,Ht hemodialysis diem,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9339,Hit periton dialysis diem,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9370,Ht inj antiemetic diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9372,Ht inj anticoag diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9445,Pt education noc individ,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9446,Pt education noc group,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9452,Nutrition class,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9453,Smoking cessation class,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9455,"Diabetic management program,",Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9465,"Diabetic management program,",Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9470,"Nutritional counseling, diet",Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9472,Cardiac rehabilitation progr,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9473,Pulmonary rehabilitation pro,Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9475,Ambulatory setting substance,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9476,Vestibular rehab per diem,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9480,Intensive outpatient psychia,Behavioral Health,Per Unit,$339.88 ,OP,$339.88 ,$339.88 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9482,Family stabilization 15 min,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9484,Crisis intervention per hour,Behavioral Health,Per Unit,$135.70 ,OP,$135.70 ,$135.70 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9485,Crisis intervention mental h,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9537,Ht hem horm inj diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9538,Hit blood products diem,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9558,Ht inj growth horm diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9559,Hit inj interferon diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9560,Ht inj hormone diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,S9562,Ht inj palivizumab diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,T1006,Family/couple counseling,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,T1007,Treatment plan development,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,T1012,Alcohol/substance abuse skil,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,T1016,Case management,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,T1017,Targeted case management,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,T1023,Program intake assessment,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,T1040,Comm bh clinic svc per diem,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,T2022,"Case management, per month",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,T2023,Targeted case mgmt per month,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,U0001,2019-ncov diagnostic p,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,U0002,Covid-19 lab test non-cdc,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,U0005,Infec agen detec ampli probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,V2785,Corneal tissue processing,Ophthalmology,Per Unit,"$1,390.89 ",OP,"$1,390.89 ","$1,390.89 ",,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,V2790,Amniotic membrane,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,V5362,Speech screening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,V5363,Language screening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Aetna Better Health Medicaid,CPT,V5364,Dysphagia screening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$463,441.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$254,896.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$303,857.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$189,792.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$163,572.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$75,067.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-007,LUNG TRANSPLANT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$185,188.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$86,828.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$57,883.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$80,262.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$61,310.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-013,TRACHEOSTOMY FOR FACE - MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$43,528.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$204,460.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$107,619.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$77,283.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$597,264.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$106,590.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$165,121.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$120,505.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$77,753.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$90,596.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$62,920.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$71,867.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$48,928.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,188.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$93,120.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$52,720.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$37,713.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$69,857.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$35,395.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,531.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$63,593.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$37,393.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,619.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$52,395.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,516.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,224.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$63,324.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$37,617.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,158.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,521.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,177.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,852.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,694.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$34,996.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,227.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,787.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,024.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,649.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-061,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$46,211.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-062,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,795.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,358.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,608.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,291.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,374.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,793.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,577.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,822.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,172.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,339.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,190.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,294.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,016.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,694.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,184.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,628.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,472.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,352.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,129.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,467.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,467.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,902.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,366.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,801.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-088,CONCUSSION WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,348.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-089,CONCUSSION WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,979.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,676.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,382.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,777.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,500.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$58,129.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,128.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$37,304.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$60,041.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,774.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,356.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-100,SEIZURES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,977.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-101,SEIZURES WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,192.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-102,HEADACHES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,427.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-103,HEADACHES W/O MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,251.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$35,068.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,128.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,252.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,035.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,622.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,019.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,300.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,244.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,380.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,366.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$34,249.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,088.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,497.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,489.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,628.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$63,689.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$35,320.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,740.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$47,420.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,008.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-145,OTHER EAR - NOSE - MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,416.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,529.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,817.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,580.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-149,DYSEQUILIBRIUM,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,768.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-150,EPISTAXIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,195.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,792.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,230.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,369.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,680.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,508.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-156,OTHER EAR - NOSE - MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,521.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,158.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,225.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,492.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$79,377.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$42,227.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,617.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$60,660.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,790.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,905.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,707.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,187.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,524.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,294.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,937.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,804.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,934.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,600.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,889.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,630.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,377.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,691.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,515.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,649.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,596.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,982.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,129.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,118.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,971.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,808.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,640.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,777.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,089.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,876.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,601.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,200.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,352.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,449.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,288.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,680.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,916.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,147.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$91,622.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,676.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$178,526.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$166,881.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$103,884.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$82,291.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$128,881.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$86,398.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$72,836.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$134,737.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$99,393.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$117,795.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$90,028.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$105,788.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$84,030.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$99,444.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$63,808.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$135,843.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$94,372.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$124,683.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$85,078.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$96,483.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$65,292.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$76,939.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$44,638.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,462.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$59,560.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,521.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,051.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$86,624.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$50,011.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,811.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$50,782.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,068.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,364.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,556.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$53,131.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$42,459.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,952.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,688.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,289.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,576.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$51,220.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,923.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$57,347.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,860.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,329.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,884.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$51,964.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$53,803.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$113,555.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$89,614.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$111,273.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$69,033.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$82,905.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$57,033.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$43,020.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$61,395.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$52,566.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,019.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,913.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,608.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,833.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,747.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$7,942.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$35,425.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI - WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,400.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$42,896.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,281.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,377.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,454.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,321.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,441.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,513.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,700.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,516.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,273.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$7,811.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,502.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,675.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,880.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,496.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,822.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-304,HYPERTENSION WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,529.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,816.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,059.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,894.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,188.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,990.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$8,934.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-311,ANGINA PECTORIS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,152.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-313,CHEST PAIN,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,532.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,334.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,603.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,992.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$69,052.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$39,099.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$86,043.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$41,753.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,648.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$77,604.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,624.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,361.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$66,555.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$34,256.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,747.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$62,246.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,526.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,121.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$44,780.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,120.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,654.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$37,059.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,929.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,750.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$44,814.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,243.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,400.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$39,385.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,478.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,668.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$39,238.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,846.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,648.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$48,132.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,528.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,747.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$68,662.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,059.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,424.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,076.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,961.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,652.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,441.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,896.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,086.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,278.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,323.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,782.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,891.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,193.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,129.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,955.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,292.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,974.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,278.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,905.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,896.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,416.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,188.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,148.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$9,321.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,910.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,230.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,457.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,017.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,395.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$91,688.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-406,PANCREAS - LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$46,032.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-407,PANCREAS - LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,856.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$59,992.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,828.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,051.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$60,038.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,411.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,702.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$58,008.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,510.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,755.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$38,776.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,009.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,043.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$56,225.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,542.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,222.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$66,864.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,505.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,692.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,113.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,456.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$9,913.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,044.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,923.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,312.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,540.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,510.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$9,694.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,139.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,905.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,604.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,700.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,059.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$147,097.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$97,569.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$76,656.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$137,569.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$104,032.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$80,278.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$107,708.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$62,923.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$97,219.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$50,307.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$85,846.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$47,592.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,497.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$85,520.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$57,219.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$44,864.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$49,350.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,398.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$80,268.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$48,851.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,643.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$65,164.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$35,097.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,556.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$53,710.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$37,710.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,948.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$48,392.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,528.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,348.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$38,180.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$54,521.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$34,374.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,244.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,593.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,771.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$55,491.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$37,203.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,630.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$58,147.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,769.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,339.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$41,348.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,179.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$50,462.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,920.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,292.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$42,059.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,611.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,356.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,624.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-509,ARTHROSCOPY,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,780.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$43,691.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,496.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,899.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,944.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-514,HAND OR WRIST PROCEDURES - EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,907.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$50,192.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,377.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,347.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$57,348.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,323.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,678.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$49,014.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$35,025.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,601.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,617.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,740.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,345.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,931.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,542.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,059.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,724.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,449.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,884.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,692.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,419.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$39,992.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,305.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,328.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,473.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-549,SEPTIC ARTHRITIS W CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,950.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,123.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,969.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,072.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,292.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,646.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,804.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,900.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-557,TENDONITIS - MYOSITIS AND BURSITIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,302.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,732.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,886.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,222.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,528.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,932.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,220.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,100.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,024.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$45,380.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,124.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,641.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$88,596.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$51,944.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,184.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$80,961.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,758.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,515.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$46,844.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,649.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,158.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,265.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,665.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,284.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,876.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-592,SKIN ULCERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,987.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-593,SKIN ULCERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,188.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,099.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,193.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,827.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,187.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,779.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,739.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,931.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,001.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-602,CELLULITIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,985.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,516.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-604,TRAUMA TO THE SKIN - SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,860.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,547.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,176.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,209.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$38,188.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,185.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$63,820.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,545.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,848.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$48,977.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,177.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,542.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$57,804.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE - NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,966.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,508.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$45,459.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-626,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,436.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-627,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,908.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$59,169.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$37,548.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,510.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-637,DIABETES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,995.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-638,DIABETES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,070.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$9,748.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,644.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,048.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,600.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,612.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,292.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,284.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$72,209.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$59,097.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$50,910.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$87,187.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$46,403.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,281.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$52,507.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,945.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,265.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$42,636.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,094.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,030.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$46,876.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,518.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,947.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$48,587.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,748.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,918.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$44,081.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,624.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,427.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,414.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$55,409.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$38,086.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,032.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-682,RENAL FAILURE WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,523.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-683,RENAL FAILURE WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,049.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$9,720.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,971.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,764.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,964.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,780.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,675.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-693,URINARY STONES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,300.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,668.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,180.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,035.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-697,URETHRAL STRICTURE,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,952.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,707.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,403.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,916.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,729.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,862.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,990.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,598.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$34,084.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,920.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,865.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,856.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,302.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,424.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,776.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,779.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,344.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,425.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,390.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,510.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,892.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,689.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,856.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,076.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$9,051.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-734,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$35,564.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-735,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,616.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$68,131.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,931.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,625.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$61,147.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,800.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,472.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,472.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,116.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,704.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,728.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-746,VAGINA - CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,750.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,008.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,572.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$43,318.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,454.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,136.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,041.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,657.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,353.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,472.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,931.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,761.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$9,440.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Vaginal Delivery,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,732.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,926.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,209.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,300.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-779,ABORTION WITHOUT D&C,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,646.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,C-Section,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,963.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,C-Section,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,518.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,C-Section,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,644.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,C-Section,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,457.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,C-Section,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,003.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,C-Section,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,193.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Neonate,Per Diem,"$1,275.00 ",IP,$600.00 ,"$27,496.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Neonate,Per Diem,"$1,275.00 ",IP,$600.00 ,"$90,673.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Neonate,Per Diem,"$1,275.00 ",IP,$600.00 ,"$61,926.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Neonate,Per Diem,"$1,275.00 ",IP,$600.00 ,"$37,364.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Neonate,Per Diem,"$1,275.00 ",IP,$600.00 ,"$63,611.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Neonate,Per Diem,"$1,275.00 ",IP,$600.00 ,"$22,515.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-795,NORMAL NEWBORN,Normal Newborn,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Vaginal Delivery,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,086.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Vaginal Delivery,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,718.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Vaginal Delivery,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,236.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$82,302.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$47,222.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,936.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$59,339.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,156.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,827.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Vaginal Delivery,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,428.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Vaginal Delivery,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,742.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Vaginal Delivery,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,257.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$34,846.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,547.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,371.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,041.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,075.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-813,COAGULATION DISORDERS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$24,715.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,251.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,880.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,574.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,828.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,064.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,966.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$90,996.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$34,481.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,025.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$71,953.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$37,803.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$22,411.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$80,588.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$39,961.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,843.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$51,291.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,624.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,937.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,476.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$8,576.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$96,801.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,819.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,713.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$91,185.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,140.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,780.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$51,451.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,932.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,524.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,446.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,888.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,558.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$42,718.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,363.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,464.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-849,RADIOTHERAPY,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$39,800.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$79,113.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$33,510.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,920.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$72,731.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,555.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,574.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,060.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,638.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,000.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,662.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$35,672.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,934.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,616.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$102,796.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,891.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,345.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$52,180.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Psychiatric,Per Diem,"$1,275.00 ",IP,$550.00 ,"$13,817.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-881,DEPRESSIVE NEUROSES,Psychiatric,Per Diem,"$1,275.00 ",IP,$550.00 ,"$12,822.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Psychiatric,Per Diem,"$1,275.00 ",IP,$550.00 ,"$13,168.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Psychiatric,Per Diem,"$1,275.00 ",IP,$550.00 ,"$25,252.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Psychiatric,Per Diem,"$1,275.00 ",IP,$550.00 ,"$23,100.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-885,PSYCHOSES,Psychiatric,Per Diem,"$1,275.00 ",IP,$550.00 ,"$19,793.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Psychiatric,Per Diem,"$1,275.00 ",IP,$550.00 ,"$19,544.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Psychiatric,Per Diem,"$1,275.00 ",IP,$550.00 ,"$17,259.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Substance Abuse,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$8,760.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Substance Abuse,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,472.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-896,ALCOHOL - DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Substance Abuse,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,432.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Substance Abuse,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$13,208.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$68,195.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,398.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,150.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$59,542.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,345.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$28,700.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$63,313.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$32,646.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,993.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,182.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$27,161.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$10,516.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,640.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$29,350.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$16,436.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,062.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$25,401.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,886.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$336,494.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$104,419.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$48,142.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$36,121.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$31,044.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-935,NON-EXTENSIVE BURNS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,932.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$54,179.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$35,481.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$30,795.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-945,REHABILITATION WITH CC/MCC,Rehabilitation,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,755.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Rehabilitation,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$18,035.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$19,041.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$12,569.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,713.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$11,822.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$8,931.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$100,608.00 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$61,580.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$118,732.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$67,286.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$43,747.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$43,587.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$23,814.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$14,606.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$92,598.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$47,121.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$42,971.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$20,465.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$15,185.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$21,132.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$73,724.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$40,659.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,476.80 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$52,193.60 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$26,891.20 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$17,854.40 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Other,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,DRG,MS-999,UNGROUPABLE,Other,Per Diem,"$1,275.00 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,ExceptPatType,14,,Swing Bed,Per Diem,$640.00 ,IP,$640.00 ,"$4,816.25 ",,,,,,,,,,,,
BCBS PPO/PPO Plus,ExceptRevenueCode,278,Medical/Surgical Supplies: Other implants,Implants,Straight Discount,100.00%,OP,,,,,,,,,,,,,,
BCBS PPO/PPO Plus,ExceptRevenueCode,360,Operating Room Services,Outpatient Surgery,Straight Discount,72.00%,OP,,,,,,,,,,,,,,
BCBS PPO/PPO Plus,ExceptRevenueCode,361,Operating Room Services: Minor surgery,Outpatient Surgery,Straight Discount,72.00%,OP,,,,,,,,,,,,,,
BCBS PPO/PPO Plus,ExceptRevenueCode,369,Operating Room Services: Other operating room services,Outpatient Surgery,Straight Discount,72.00%,OP,,,,,,,,,,,,,,
BCBS PPO/PPO Plus,ExceptRevenueCode,480,Cardiology,Outpatient Surgery,Straight Discount,72.00%,OP,,,,,,,,,,,,,,
BCBS PPO/PPO Plus,ExceptRevenueCode,490,Ambulatory Surgery,Outpatient Surgery,Straight Discount,72.00%,OP,,,,,,,,,,,,,,
BCBS PPO/PPO Plus,ExceptRevenueCode,761,Treatment/Observation Room: Treatment room,Observation,Straight Discount,72.00%,OP,,,,,,,,,,,,,,
BCBS PPO/PPO Plus,ExceptRevenueCode,762,Treatment/Observation Room: Observation room,Observation,Straight Discount,72.00%,OP,,,,,,,,,,,,,,
BCBS PPO/PPO Plus,,,,All Other,Straight Discount,72.00%,OP,,,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,ExceptPatType,14,,Swing Bed,Per Diem,"$4,816.25 ",IP,$640.00 ,"$4,816.25 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$463,441.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$254,896.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$303,857.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$189,792.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$163,572.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$75,067.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-007,LUNG TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$185,188.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$86,828.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-010,PANCREAS TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,883.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,262.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$61,310.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-013,TRACHEOSTOMY FOR FACE - MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,528.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$204,460.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$107,619.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$77,283.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$597,264.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$106,590.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$165,121.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$120,505.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$77,753.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$90,596.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$62,920.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$71,867.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,928.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,188.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$93,120.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,720.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,713.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$69,857.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,395.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,531.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,593.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,393.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,619.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,395.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,516.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,224.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,324.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,617.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,158.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,521.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,177.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,852.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,694.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,996.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,227.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,787.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,024.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,649.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-061,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,211.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-062,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,795.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,358.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,608.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,291.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,374.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,793.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,577.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,822.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,172.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,339.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,190.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,294.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,016.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,694.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,184.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,628.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,472.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,352.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,129.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,467.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,467.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,902.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,366.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,801.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-088,CONCUSSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,348.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-089,CONCUSSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,979.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,676.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,382.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,777.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,500.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$58,129.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,128.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,304.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$60,041.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,774.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,356.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-100,SEIZURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,977.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-101,SEIZURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,192.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-102,HEADACHES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,427.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-103,HEADACHES W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,251.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,068.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,128.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,252.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,035.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,622.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,019.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,300.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,244.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,380.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,366.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,249.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,088.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,497.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,489.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-139,SALIVARY GLAND PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,628.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,689.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,320.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,740.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$47,420.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,008.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-145,OTHER EAR - NOSE - MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,416.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,529.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,817.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,580.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-149,DYSEQUILIBRIUM,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,768.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-150,EPISTAXIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,195.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-151,EPISTAXIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,792.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,230.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,369.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,680.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,508.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-156,OTHER EAR - NOSE - MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,521.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,158.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,225.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,492.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$79,377.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,227.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,617.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$60,660.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,790.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,905.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,707.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,187.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,524.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,294.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,937.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,804.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,934.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,600.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,889.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,630.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,377.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,691.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-187,PLEURAL EFFUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,515.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,649.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,596.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,982.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,129.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,118.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,971.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,808.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,640.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,777.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,089.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,876.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-199,PNEUMOTHORAX WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,601.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-200,PNEUMOTHORAX WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,200.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,352.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,449.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,288.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,680.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,916.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,147.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$91,622.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,676.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$178,526.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$166,881.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$103,884.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$82,291.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$128,881.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$86,398.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$72,836.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$134,737.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$99,393.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$117,795.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$90,028.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$105,788.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$84,030.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$99,444.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,808.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$135,843.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$94,372.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$124,683.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$85,078.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$96,483.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$65,292.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$76,939.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,638.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,462.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,560.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,521.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,051.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-245,AICD GENERATOR PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$86,624.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,011.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,811.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,782.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,068.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,364.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,556.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$53,131.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,459.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,952.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,688.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,289.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,576.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,220.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,923.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,347.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,860.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,329.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-263,VEIN LIGATION AND STRIPPING,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,884.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,964.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-265,AICD LEAD PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$53,803.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$113,555.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$89,614.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$111,273.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$69,033.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$82,905.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,033.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,020.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$61,395.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,566.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,019.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,913.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,608.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,833.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,747.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$7,942.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,425.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI - WITH CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,400.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,896.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,281.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,377.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,454.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,321.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,441.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,513.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,700.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,516.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,273.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$7,811.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,502.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,675.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,880.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,496.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,822.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-304,HYPERTENSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,529.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-305,HYPERTENSION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,816.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,059.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,894.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,188.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,990.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$8,934.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-311,ANGINA PECTORIS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,152.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-312,SYNCOPE AND COLLAPSE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-313,CHEST PAIN,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,532.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,334.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,603.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,992.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$69,052.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,099.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$86,043.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$41,753.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,648.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$77,604.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,624.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,361.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-332,RECTAL RESECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$66,555.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-333,RECTAL RESECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,256.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,747.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$62,246.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,526.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,121.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,780.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,120.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,654.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,059.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,929.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,750.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,814.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,243.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,400.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,385.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,478.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,668.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,238.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,846.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,648.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,132.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,528.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,747.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$68,662.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,059.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,424.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,076.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,961.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,652.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,441.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,896.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,086.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,278.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,323.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,782.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,891.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,193.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,129.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,955.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,292.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,974.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,278.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,905.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,896.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,416.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,188.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,148.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,321.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,910.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,230.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,457.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,017.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,395.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$91,688.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-406,PANCREAS - LIVER AND SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,032.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-407,PANCREAS - LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,856.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,992.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,828.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,051.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$60,038.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,411.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,702.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$58,008.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,510.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,755.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$38,776.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,009.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,043.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$56,225.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,542.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,222.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$66,864.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,505.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,692.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,113.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,456.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,913.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,044.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,923.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,312.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,540.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,510.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,694.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,139.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,905.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,604.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,700.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,059.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$147,097.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$97,569.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$76,656.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$137,569.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$104,032.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,278.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$107,708.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$62,923.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$97,219.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,307.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$85,846.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$47,592.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,497.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$85,520.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,219.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,864.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$49,350.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,398.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,268.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,851.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,643.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$65,164.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,097.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,556.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$53,710.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,710.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,948.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,392.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,528.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,348.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$38,180.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$54,521.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,374.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,244.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,593.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,771.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$55,491.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,203.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,630.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$58,147.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,769.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,339.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$41,348.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,179.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,462.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,920.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,292.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-503,FOOT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,059.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-504,FOOT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,611.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,356.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,624.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-509,ARTHROSCOPY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,780.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,691.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,496.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,899.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,944.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-514,HAND OR WRIST PROCEDURES - EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,907.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,192.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,377.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,347.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,348.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,323.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,678.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$49,014.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,025.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,601.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,617.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,740.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,345.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,931.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,542.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-539,OSTEOMYELITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,059.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-540,OSTEOMYELITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,724.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,449.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,884.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,692.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,419.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,992.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,305.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,328.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,473.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-549,SEPTIC ARTHRITIS W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,950.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,123.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,969.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,072.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,292.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,646.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,804.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,900.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-557,TENDONITIS - MYOSITIS AND BURSITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,302.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,732.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,886.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,222.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,528.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,932.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,220.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,100.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,024.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$45,380.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,124.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,641.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$88,596.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,944.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,184.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,961.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,758.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,515.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,844.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,649.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,158.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,265.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,665.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,284.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,876.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-592,SKIN ULCERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,987.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-593,SKIN ULCERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,188.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,099.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,193.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,827.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,187.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,779.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,739.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,931.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,001.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-602,CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,985.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-603,CELLULITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,516.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-604,TRAUMA TO THE SKIN - SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,860.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,547.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,176.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,209.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$38,188.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,185.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,820.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,545.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,848.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,977.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,177.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,542.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,804.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE - NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,966.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,508.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$45,459.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-626,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,436.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-627,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,908.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,169.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,548.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,510.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-637,DIABETES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,995.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-638,DIABETES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,070.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-639,DIABETES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,748.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,644.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,048.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,600.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,612.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,292.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,284.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$72,209.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,097.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-652,KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,910.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$87,187.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,403.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,281.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,507.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,945.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,265.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,636.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,094.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,030.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,876.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,518.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,947.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-665,PROSTATECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,587.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-666,PROSTATECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,748.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,918.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,081.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,624.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,427.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,414.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$55,409.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$38,086.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,032.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-682,RENAL FAILURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,523.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-683,RENAL FAILURE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,049.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,720.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,971.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,764.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,964.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,780.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,675.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-693,URINARY STONES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,300.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-694,URINARY STONES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,668.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,180.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,035.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-697,URETHRAL STRICTURE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,952.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,707.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,403.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,916.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,729.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,862.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,990.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,598.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,084.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,920.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,865.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,856.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,302.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,424.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,776.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,779.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,344.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,425.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,390.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,510.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,892.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,689.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,856.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,076.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,051.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-734,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,564.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-735,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,616.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$68,131.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,931.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,625.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$61,147.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,800.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,472.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,472.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,116.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,704.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,728.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-746,VAGINA - CERVIX AND VULVA PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,750.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,008.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,572.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,318.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,454.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,136.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,041.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,657.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,353.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,472.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,931.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,761.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,440.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,732.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,926.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,209.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,300.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-779,ABORTION WITHOUT D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,646.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,963.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,518.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,644.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,457.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,003.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,193.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$27,496.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$90,673.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$61,926.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$37,364.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$63,611.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$22,515.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-795,NORMAL NEWBORN,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,086.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,718.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,236.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-799,SPLENECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$82,302.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-800,SPLENECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$47,222.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,936.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,339.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,156.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,827.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,428.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,742.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,257.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,846.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,547.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,371.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,041.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,075.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-813,COAGULATION DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,715.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,251.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,880.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,574.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,828.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,064.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,966.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$90,996.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,481.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,025.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$71,953.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,803.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,411.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,588.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,961.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,843.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,291.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,624.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,937.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,476.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$8,576.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$96,801.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,819.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,713.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$91,185.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,140.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,780.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,451.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,932.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,524.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,446.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,888.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,558.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,718.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,363.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,464.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-849,RADIOTHERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,800.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$79,113.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,510.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,920.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$72,731.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,555.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,574.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,060.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,638.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,000.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-865,VIRAL ILLNESS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,662.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,672.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,934.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,616.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$102,796.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,891.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,345.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,180.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$13,817.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-881,DEPRESSIVE NEUROSES,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$12,822.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$13,168.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$25,252.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$23,100.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-885,PSYCHOSES,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$19,793.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$19,544.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$17,259.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$8,760.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,472.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-896,ALCOHOL - DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,432.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,208.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$68,195.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,398.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,150.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,542.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,345.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,700.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,313.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,646.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,993.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,182.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,161.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,516.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,640.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,350.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,436.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,062.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,401.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,886.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$336,494.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$104,419.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,142.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,121.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,044.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-935,NON-EXTENSIVE BURNS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,932.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$54,179.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,481.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,795.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-945,REHABILITATION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,755.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,035.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,041.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,569.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-949,AFTERCARE WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,713.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,822.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$8,931.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$100,608.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$61,580.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$118,732.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$67,286.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,747.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,587.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,814.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,606.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$92,598.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$47,121.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,971.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,465.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,185.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,132.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$73,724.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,659.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,476.80 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,193.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,891.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,854.40 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,DRG,MS-999,UNGROUPABLE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,$3.00 ,$3.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,$11.06 ,$11.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,$94.41 ,$94.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,$13.73 ,$13.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,$8.46 ,$8.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,$7.01 ,$7.01 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,$10.56 ,$10.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,$47.81 ,$47.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,$13.39 ,$13.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,$8.68 ,$8.68 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,$47.63 ,$47.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,$8.17 ,$8.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,$74.86 ,$74.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,$15.08 ,$15.08 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,$14.57 ,$14.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,$18.05 ,$18.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,$20.15 ,$20.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,$13.28 ,$13.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,$13.28 ,$13.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,$13.54 ,$13.54 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,$13.54 ,$13.54 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,$16.34 ,$16.34 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,$13.73 ,$13.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,$16.38 ,$16.38 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,$21.67 ,$21.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,$15.78 ,$15.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,$6.61 ,$6.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,$18.05 ,$18.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,$15.30 ,$15.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,$13.76 ,$13.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,$16.59 ,$16.59 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,$60.00 ,$60.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,$16.75 ,$16.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,$14.60 ,$14.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,$13.73 ,$13.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,$13.73 ,$13.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,$14.14 ,$14.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,$16.13 ,$16.13 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,$11.92 ,$11.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,$13.54 ,$13.54 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,$12.60 ,$12.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,$17.14 ,$17.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,$62.14 ,$62.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,$32.62 ,$32.62 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,$86.96 ,$86.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,$78.26 ,$78.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,$125.50 ,$125.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,$80.37 ,$80.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,$801.62 ,$801.62 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,$51.64 ,$51.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,$55.89 ,$55.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,$209.32 ,$209.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,$43.99 ,$43.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,$579.48 ,$579.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,$161.88 ,$161.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,$46.07 ,$46.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,$50.50 ,$50.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,$148.41 ,$148.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,$66.70 ,$66.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,$129.33 ,$129.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,$165.61 ,$165.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,$285.03 ,$285.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,$103.00 ,$103.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,$91.16 ,$91.16 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,$50.41 ,$50.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,$67.21 ,$67.21 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,$4.02 ,$4.02 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,$3.17 ,$3.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,$3.48 ,$3.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,$2.25 ,$2.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,$2.17 ,$2.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,$29.98 ,$29.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,$3.05 ,$3.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,$4.70 ,$4.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,$8.61 ,$8.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,$3.64 ,$3.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,$295.79 ,$295.79 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,$279.00 ,$279.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"$1,824.88 ","$1,824.88 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,$468.00 ,$468.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,$584.23 ,$584.23 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,$300.00 ,$300.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,$676.50 ,$676.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,$241.90 ,$241.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,$846.27 ,$846.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,$518.28 ,$518.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,$47.25 ,$47.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,$780.00 ,$780.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,$280.00 ,$280.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,$200.00 ,$200.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,$94.99 ,$94.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,$163.96 ,$163.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,$144.84 ,$144.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,$214.62 ,$214.62 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,$39.31 ,$39.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,$440.00 ,$440.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,$185.12 ,$185.12 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,$241.90 ,$241.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,$121.63 ,$121.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,$556.60 ,$556.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,$97.22 ,$97.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,$435.07 ,$435.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,$499.00 ,$499.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,$168.75 ,$168.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,$291.36 ,$291.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,$900.00 ,$900.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"$1,160.00 ","$1,160.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,$324.58 ,$324.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,$65.69 ,$65.69 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,$73.37 ,$73.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,$36.62 ,$36.62 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,$57.04 ,$57.04 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,$44.89 ,$44.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,$165.51 ,$165.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,$83.00 ,$83.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,$58.49 ,$58.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,$47.25 ,$47.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,$101.12 ,$101.12 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,$61.52 ,$61.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,$35.00 ,$35.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,$51.45 ,$51.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,$65.36 ,$65.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,$102.26 ,$102.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,$39.31 ,$39.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,$197.99 ,$197.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,$68.55 ,$68.55 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,$294.52 ,$294.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,$172.73 ,$172.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,$233.07 ,$233.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,$304.81 ,$304.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,$207.46 ,$207.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,$260.79 ,$260.79 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,$202.40 ,$202.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,$91.66 ,$91.66 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,$329.51 ,$329.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,$124.87 ,$124.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"$1,160.00 ","$1,160.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,$73.37 ,$73.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,$124.64 ,$124.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,$192.32 ,$192.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,$39.31 ,$39.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,$65.34 ,$65.34 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,$675.40 ,$675.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,$331.00 ,$331.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,$202.40 ,$202.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,$381.70 ,$381.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,$337.73 ,$337.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,$213.30 ,$213.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,$641.85 ,$641.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,$308.00 ,$308.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,$238.00 ,$238.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,$348.56 ,$348.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,$527.87 ,$527.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,$120.00 ,$120.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,$150.00 ,$150.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,$291.36 ,$291.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,$676.50 ,$676.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,$246.52 ,$246.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,$295.79 ,$295.79 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,$255.05 ,$255.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,$329.51 ,$329.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,$676.50 ,$676.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,$331.00 ,$331.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,$203.50 ,$203.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,$291.36 ,$291.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,$46.60 ,$46.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,$300.00 ,$300.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,$758.36 ,$758.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,$769.58 ,$769.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,$46.60 ,$46.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,$192.00 ,$192.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,$47.00 ,$47.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,$51.07 ,$51.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,$43.65 ,$43.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,$329.51 ,$329.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,$150.33 ,$150.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,$208.92 ,$208.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,$49.59 ,$49.59 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,$201.50 ,$201.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,$234.00 ,$234.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,$641.85 ,$641.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,$329.51 ,$329.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,$308.00 ,$308.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,$88.20 ,$88.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,$202.40 ,$202.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,$324.58 ,$324.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,$402.12 ,$402.12 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,$404.52 ,$404.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,$403.59 ,$403.59 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,$127.43 ,$127.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,$74.33 ,$74.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,$220.74 ,$220.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,$94.74 ,$94.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,$345.57 ,$345.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,$335.38 ,$335.38 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,$177.25 ,$177.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,$169.90 ,$169.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,$123.68 ,$123.68 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,$109.13 ,$109.13 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,$63.96 ,$63.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,$150.33 ,$150.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,$846.27 ,$846.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"$2,000.00 ","$2,000.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,$504.00 ,$504.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"$1,350.19 ","$1,350.19 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"$2,448.56 ","$2,448.56 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"$4,780.00 ","$4,780.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"$12,000.00 ","$12,000.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,$320.00 ,$320.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"$2,448.56 ","$2,448.56 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,$759.05 ,$759.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,$759.05 ,$759.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"$5,031.20 ","$5,031.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"$2,709.95 ","$2,709.95 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"$2,337.65 ","$2,337.65 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"$1,625.00 ","$1,625.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,$679.57 ,$679.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,$679.05 ,$679.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,$438.93 ,$438.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,$597.91 ,$597.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,$438.93 ,$438.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,$438.93 ,$438.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"$3,324.00 ","$3,324.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"$2,143.60 ","$2,143.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"$2,448.56 ","$2,448.56 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,$597.91 ,$597.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,$759.53 ,$759.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"$2,919.60 ","$2,919.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"$1,287.00 ","$1,287.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,$936.00 ,$936.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,$914.00 ,$914.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,$914.00 ,$914.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,$840.65 ,$840.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"$1,050.00 ","$1,050.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,$260.50 ,$260.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,$897.00 ,$897.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,$520.00 ,$520.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,$68.92 ,$68.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,$795.00 ,$795.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,$54.30 ,$54.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,"$1,487.37 ","$1,487.37 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,$55.54 ,$55.54 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,$153.50 ,$153.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,$69.52 ,$69.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,$142.63 ,$142.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,$262.99 ,$262.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"$2,510.21 ","$2,510.21 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"$3,116.00 ","$3,116.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,$508.87 ,$508.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"$7,193.00 ","$7,193.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,$579.46 ,$579.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,$177.56 ,$177.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"$2,871.00 ","$2,871.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"$3,750.00 ","$3,750.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"$3,600.00 ","$3,600.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"$2,030.00 ","$2,030.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"$7,776.00 ","$7,776.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"$5,500.00 ","$5,500.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"$3,240.00 ","$3,240.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,$72.19 ,$72.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,$4.52 ,$4.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,$8.17 ,$8.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,$12.29 ,$12.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,$16.49 ,$16.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,$38.62 ,$38.62 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,$25.80 ,$25.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,$7.78 ,$7.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,$5.78 ,$5.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,$6.23 ,$6.23 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,$33.94 ,$33.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,$30.00 ,$30.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,$17.27 ,$17.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,$9.71 ,$9.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,$40.75 ,$40.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,$13.44 ,$13.44 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,$14.46 ,$14.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,$16.77 ,$16.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,$17.00 ,$17.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,$64.41 ,$64.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,$25.48 ,$25.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,$5.99 ,$5.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,$14.18 ,$14.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,$13.87 ,$13.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,$22.98 ,$22.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,$16.45 ,$16.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,$19.61 ,$19.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,$14.57 ,$14.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,$9.35 ,$9.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,$6.48 ,$6.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,$28.83 ,$28.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,$29.28 ,$29.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,$25.55 ,$25.55 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,$20.52 ,$20.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,$14.60 ,$14.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,$21.09 ,$21.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,$18.97 ,$18.97 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,$9.89 ,$9.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,$15.90 ,$15.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,$16.18 ,$16.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,$17.12 ,$17.12 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,$26.58 ,$26.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,$5.02 ,$5.02 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,$5.02 ,$5.02 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,$4.56 ,$4.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,$4.38 ,$4.38 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,$5.32 ,$5.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,$4.23 ,$4.23 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,$15.92 ,$15.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,$5.16 ,$5.16 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,$23.64 ,$23.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,$29.60 ,$29.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,$26.79 ,$26.79 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,$5.16 ,$5.16 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,$13.68 ,$13.68 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,$13.34 ,$13.34 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,$6.03 ,$6.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,$11.58 ,$11.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,$12.90 ,$12.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,$12.52 ,$12.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,$18.06 ,$18.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,$4.88 ,$4.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,$12.32 ,$12.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,$14.07 ,$14.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,$18.96 ,$18.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,$9.22 ,$9.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,$27.30 ,$27.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,$29.08 ,$29.08 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,$25.25 ,$25.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,$18.06 ,$18.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,$14.12 ,$14.12 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,$12.67 ,$12.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,$4.60 ,$4.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,$5.00 ,$5.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,$6.01 ,$6.01 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,$4.35 ,$4.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,$7.87 ,$7.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,$9.81 ,$9.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,$20.65 ,$20.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,$20.28 ,$20.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,$27.80 ,$27.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,$18.68 ,$18.68 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,$12.41 ,$12.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,$22.52 ,$22.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,$16.71 ,$16.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,$16.30 ,$16.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,$4.64 ,$4.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,$24.09 ,$24.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,$6.51 ,$6.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,$13.39 ,$13.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,$11.55 ,$11.55 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,$11.87 ,$11.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,$5.12 ,$5.12 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,$9.46 ,$9.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,$14.14 ,$14.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,$19.40 ,$19.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,$15.08 ,$15.08 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,$14.32 ,$14.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,$18.52 ,$18.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,$9.55 ,$9.55 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,$25.27 ,$25.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,$22.23 ,$22.23 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,$30.98 ,$30.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,$29.28 ,$29.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,$12.25 ,$12.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,$29.28 ,$29.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,$38.50 ,$38.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,$22.17 ,$22.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,$44.03 ,$44.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,$61.50 ,$61.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,$18.79 ,$18.79 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,$27.94 ,$27.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,$32.30 ,$32.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,$21.70 ,$21.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,$24.18 ,$24.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,$24.95 ,$24.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,$27.94 ,$27.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,$14.90 ,$14.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,$26.24 ,$26.24 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,$5.10 ,$5.10 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,$16.80 ,$16.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,$22.97 ,$22.97 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,$18.77 ,$18.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,$19.75 ,$19.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,$13.63 ,$13.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,$64.41 ,$64.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,$18.54 ,$18.54 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,$14.70 ,$14.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,$17.65 ,$17.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,$17.34 ,$17.34 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,$21.48 ,$21.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,$11.20 ,$11.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,$21.07 ,$21.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,$11.74 ,$11.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,$44.25 ,$44.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,$9.30 ,$9.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,$16.46 ,$16.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,$8.02 ,$8.02 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,$11.00 ,$11.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,$26.07 ,$26.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,$78.77 ,$78.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,$9.77 ,$9.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,$13.34 ,$13.34 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,$6.71 ,$6.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,$17.69 ,$17.69 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,$17.63 ,$17.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,$14.29 ,$14.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,$3.93 ,$3.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,$17.77 ,$17.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,$3.93 ,$3.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,$5.04 ,$5.04 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,$4.75 ,$4.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,$3.92 ,$3.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,$9.70 ,$9.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,$6.05 ,$6.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,$3.28 ,$3.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,$21.48 ,$21.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,$13.15 ,$13.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,$7.20 ,$7.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,$15.45 ,$15.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,$16.76 ,$16.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,$18.58 ,$18.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,$18.52 ,$18.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,$16.67 ,$16.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,$75.60 ,$75.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,$67.36 ,$67.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,$12.58 ,$12.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,$26.89 ,$26.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,$67.36 ,$67.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,$7.86 ,$7.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,$20.94 ,$20.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,$21.96 ,$21.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,$18.06 ,$18.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,$4.01 ,$4.01 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,$8.00 ,$8.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,$9.71 ,$9.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,$9.71 ,$9.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,$6.49 ,$6.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,$8.20 ,$8.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,$7.31 ,$7.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,$8.80 ,$8.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,$9.00 ,$9.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,$9.47 ,$9.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,$3.95 ,$3.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,$4.75 ,$4.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,$29.53 ,$29.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,$17.92 ,$17.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,$22.41 ,$22.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,$12.90 ,$12.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,$27.17 ,$27.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,$22.65 ,$22.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,$24.30 ,$24.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,$9.64 ,$9.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,$18.40 ,$18.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,$17.27 ,$17.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,$11.43 ,$11.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,$12.95 ,$12.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,$19.82 ,$19.82 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,$8.74 ,$8.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,$8.85 ,$8.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,$15.47 ,$15.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,$12.80 ,$12.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,$28.50 ,$28.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,$11.57 ,$11.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,$6.04 ,$6.04 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,$12.79 ,$12.79 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,$19.70 ,$19.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,$19.63 ,$19.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,$20.22 ,$20.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,$11.25 ,$11.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,$12.11 ,$12.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,$21.99 ,$21.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,$18.91 ,$18.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,$18.91 ,$18.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,$19.32 ,$19.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,$9.81 ,$9.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,$6.89 ,$6.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,$14.32 ,$14.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,$46.31 ,$46.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,$11.26 ,$11.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,$33.86 ,$33.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,$34.19 ,$34.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,$8.19 ,$8.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,$12.75 ,$12.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,$10.50 ,$10.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,$34.19 ,$34.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,$17.19 ,$17.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,$6.70 ,$6.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,$7.37 ,$7.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,$26.65 ,$26.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,$16.26 ,$16.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,$16.94 ,$16.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,$22.48 ,$22.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,$28.50 ,$28.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,$17.20 ,$17.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,$12.92 ,$12.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,$50.86 ,$50.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,$39.26 ,$39.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,$13.60 ,$13.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,$24.51 ,$24.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,$11.15 ,$11.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,$27.39 ,$27.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,$23.60 ,$23.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,$16.45 ,$16.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,$21.21 ,$21.21 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,$6.61 ,$6.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,$6.82 ,$6.82 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,$29.85 ,$29.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,$14.45 ,$14.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,$64.41 ,$64.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,$64.41 ,$64.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,$41.28 ,$41.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,$3.58 ,$3.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,$3.58 ,$3.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,$19.63 ,$19.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,$5.50 ,$5.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,$3.98 ,$3.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,$7.64 ,$7.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,$9.66 ,$9.66 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,$8.26 ,$8.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,$14.78 ,$14.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,$16.52 ,$16.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,$10.73 ,$10.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,$4.74 ,$4.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,$5.78 ,$5.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,$5.82 ,$5.82 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,$8.44 ,$8.44 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,$98.11 ,$98.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,$13.36 ,$13.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,$14.71 ,$14.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,$39.11 ,$39.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,$4.76 ,$4.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,$4.73 ,$4.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,$14.59 ,$14.59 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,$21.27 ,$21.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,$21.05 ,$21.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,$20.67 ,$20.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,$22.81 ,$22.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,$20.86 ,$20.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,$27.22 ,$27.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,$19.38 ,$19.38 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,$41.77 ,$41.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,$18.39 ,$18.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,$18.39 ,$18.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,$18.39 ,$18.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,$3.67 ,$3.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,$3.67 ,$3.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,$4.00 ,$4.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,$5.61 ,$5.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,$15.05 ,$15.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,$17.83 ,$17.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,$17.03 ,$17.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,$29.21 ,$29.21 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,$14.35 ,$14.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,$9.74 ,$9.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,$26.69 ,$26.69 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,$28.10 ,$28.10 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,$14.48 ,$14.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,$11.63 ,$11.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,$87.88 ,$87.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,$64.88 ,$64.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,$71.23 ,$71.23 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,$36.57 ,$36.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,$21.99 ,$21.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,$20.24 ,$20.24 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,$25.53 ,$25.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,$30.98 ,$30.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,$21.73 ,$21.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,$13.44 ,$13.44 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,$25.21 ,$25.21 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,$4.81 ,$4.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,$5.06 ,$5.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,$4.86 ,$4.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,$21.26 ,$21.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,$18.28 ,$18.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,$8.10 ,$8.10 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,$3.28 ,$3.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,$39.00 ,$39.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,$5.50 ,$5.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,$5.50 ,$5.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,$5.49 ,$5.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,$25.47 ,$25.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,$25.81 ,$25.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,$51.28 ,$51.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,$21.23 ,$21.23 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,$11.63 ,$11.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,$35.11 ,$35.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,$16.06 ,$16.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,$6.87 ,$6.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,$9.02 ,$9.02 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,$14.78 ,$14.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,$16.80 ,$16.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,$50.86 ,$50.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,$14.18 ,$14.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,$18.00 ,$18.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,$5.30 ,$5.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,$12.76 ,$12.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,$5.74 ,$5.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,$14.18 ,$14.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,$16.94 ,$16.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,$15.76 ,$15.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,$12.47 ,$12.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,$7.20 ,$7.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,$7.30 ,$7.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,$9.93 ,$9.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,$10.63 ,$10.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,$10.09 ,$10.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,$3.95 ,$3.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,$5.13 ,$5.13 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,$5.56 ,$5.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,$7.20 ,$7.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,$4.52 ,$4.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,$5.08 ,$5.08 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,$16.80 ,$16.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,$4.47 ,$4.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,$9.55 ,$9.55 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,$6.05 ,$6.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,$15.50 ,$15.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,$35.33 ,$35.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,$33.94 ,$33.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,$11.61 ,$11.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,$17.06 ,$17.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,$13.72 ,$13.72 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,$17.11 ,$17.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,$12.91 ,$12.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,$11.39 ,$11.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,$15.05 ,$15.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,$7.52 ,$7.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,$15.29 ,$15.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,$12.70 ,$12.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,$4.82 ,$4.82 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,$3.80 ,$3.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,$3.43 ,$3.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,$5.07 ,$5.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,$7.00 ,$7.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,$2.37 ,$2.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,$2.37 ,$2.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,$7.77 ,$7.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,$4.31 ,$4.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,$3.02 ,$3.02 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,$4.31 ,$4.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,$5.57 ,$5.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,$2.54 ,$2.54 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,$4.48 ,$4.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,$35.74 ,$35.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,$11.89 ,$11.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,$16.30 ,$16.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,$20.37 ,$20.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,$12.98 ,$12.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,$17.65 ,$17.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,$20.42 ,$20.42 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,$22.94 ,$22.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,$22.94 ,$22.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,$22.94 ,$22.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,$19.04 ,$19.04 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,$19.35 ,$19.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,$16.34 ,$16.34 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,$9.11 ,$9.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,$18.93 ,$18.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,$18.93 ,$18.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,$11.85 ,$11.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,$10.81 ,$10.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,$12.01 ,$12.01 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,$13.84 ,$13.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,$11.61 ,$11.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,$15.32 ,$15.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,$15.32 ,$15.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,$17.27 ,$17.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,$4.69 ,$4.69 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,$4.28 ,$4.28 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,$4.49 ,$4.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,$8.41 ,$8.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,$6.89 ,$6.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,$80.46 ,$80.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,$12.43 ,$12.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,$9.72 ,$9.72 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,$9.72 ,$9.72 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,$14.46 ,$14.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,$15.48 ,$15.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,$30.86 ,$30.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,$7.71 ,$7.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,$7.71 ,$7.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,$17.19 ,$17.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,$6.53 ,$6.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,$4.20 ,$4.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,$6.82 ,$6.82 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,$7.73 ,$7.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,$9.36 ,$9.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,$8.87 ,$8.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,$13.09 ,$13.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,$11.84 ,$11.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,$13.09 ,$13.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,$6.88 ,$6.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,$8.60 ,$8.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,$8.60 ,$8.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,$18.75 ,$18.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,$7.47 ,$7.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,$13.36 ,$13.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,$24.91 ,$24.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,$17.98 ,$17.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,$17.98 ,$17.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,$4.29 ,$4.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,$3.94 ,$3.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,$17.49 ,$17.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,$9.58 ,$9.58 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,$9.85 ,$9.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,$2.70 ,$2.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,$5.51 ,$5.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,$5.77 ,$5.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,$6.85 ,$6.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,$9.63 ,$9.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,$6.01 ,$6.01 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,$11.67 ,$11.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,$6.98 ,$6.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,$7.82 ,$7.82 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,$5.22 ,$5.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,$7.97 ,$7.97 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,$17.93 ,$17.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,$15.05 ,$15.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,$18.37 ,$18.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,$12.46 ,$12.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,$12.09 ,$12.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,$11.16 ,$11.16 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,$7.30 ,$7.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,$5.77 ,$5.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,$12.95 ,$12.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,$25.45 ,$25.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,$25.45 ,$25.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,$16.07 ,$16.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,$15.99 ,$15.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,$8.07 ,$8.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,$8.06 ,$8.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,$12.00 ,$12.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,$12.00 ,$12.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,$20.32 ,$20.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,$10.01 ,$10.01 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,$12.95 ,$12.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,$13.74 ,$13.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,$12.11 ,$12.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,$17.93 ,$17.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,$12.05 ,$12.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,$12.05 ,$12.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,$8.19 ,$8.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,$25.57 ,$25.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,$7.37 ,$7.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,$14.99 ,$14.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,$18.09 ,$18.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,$29.92 ,$29.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,$23.13 ,$23.13 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,$29.92 ,$29.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,$14.05 ,$14.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,$24.37 ,$24.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,$22.34 ,$22.34 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,$29.35 ,$29.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,$15.59 ,$15.59 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,$21.41 ,$21.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,$15.08 ,$15.08 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,$23.57 ,$23.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,$12.46 ,$12.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,$10.39 ,$10.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,$135.86 ,$135.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,$49.03 ,$49.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,$37.73 ,$37.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,$26.78 ,$26.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,$37.73 ,$37.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,$37.73 ,$37.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,$46.98 ,$46.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,$26.78 ,$26.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,$77.78 ,$77.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,$14.55 ,$14.55 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,$16.91 ,$16.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,$13.61 ,$13.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,$21.78 ,$21.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,$11.54 ,$11.54 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,$10.64 ,$10.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,$6.14 ,$6.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,$5.67 ,$5.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,$61.98 ,$61.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,$100.00 ,$100.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,$12.66 ,$12.66 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,$4.40 ,$4.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,$15.05 ,$15.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,$12.88 ,$12.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,$12.90 ,$12.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,$15.49 ,$15.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,$17.03 ,$17.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,$13.38 ,$13.38 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,$8.93 ,$8.93 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,$13.12 ,$13.12 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,$12.01 ,$12.01 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,$11.82 ,$11.82 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,$12.68 ,$12.68 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,$11.47 ,$11.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,$12.12 ,$12.12 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,$14.41 ,$14.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,$16.85 ,$16.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,$15.21 ,$15.21 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,$13.03 ,$13.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,$13.12 ,$13.12 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,$15.29 ,$15.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,$18.14 ,$18.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,$14.16 ,$14.16 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,$12.25 ,$12.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,$14.72 ,$14.72 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,$16.85 ,$16.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,$13.01 ,$13.01 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,$15.84 ,$15.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,$9.09 ,$9.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,$14.00 ,$14.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,$19.35 ,$19.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,$17.16 ,$17.16 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,$19.35 ,$19.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,$13.79 ,$13.79 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,$8.89 ,$8.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,$13.52 ,$13.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,$13.71 ,$13.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,$12.05 ,$12.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,$11.77 ,$11.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,$11.57 ,$11.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,$12.39 ,$12.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,$11.26 ,$11.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,$13.55 ,$13.55 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,$16.89 ,$16.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,$15.30 ,$15.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,$12.25 ,$12.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,$16.20 ,$16.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,$15.00 ,$15.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,$13.05 ,$13.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,$13.24 ,$13.24 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,$15.99 ,$15.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,$15.03 ,$15.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,$12.39 ,$12.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,$15.89 ,$15.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,$19.35 ,$19.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,$18.23 ,$18.23 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,$12.88 ,$12.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,$24.48 ,$24.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,$14.80 ,$14.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,$14.41 ,$14.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,$13.24 ,$13.24 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,$12.56 ,$12.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,$12.88 ,$12.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,$16.85 ,$16.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,$12.88 ,$12.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,$16.85 ,$16.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,$15.91 ,$15.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,$14.27 ,$14.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,$15.49 ,$15.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,$189.51 ,$189.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,$47.59 ,$47.59 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,$78.65 ,$78.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,$29.68 ,$29.68 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,$25.81 ,$25.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,$58.00 ,$58.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,$30.17 ,$30.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,$106.14 ,$106.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,$36.56 ,$36.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,$109.49 ,$109.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,$36.53 ,$36.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,$64.19 ,$64.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,$64.19 ,$64.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,$95.52 ,$95.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,$81.88 ,$81.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,$323.75 ,$323.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,$325.80 ,$325.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,$357.56 ,$357.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,$322.96 ,$322.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,$8.77 ,$8.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,$12.11 ,$12.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,$16.84 ,$16.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,$6.68 ,$6.68 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,$10.32 ,$10.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,$8.62 ,$8.62 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,$9.89 ,$9.89 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,$9.66 ,$9.66 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,$9.47 ,$9.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,$8.08 ,$8.08 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,$8.08 ,$8.08 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,$6.63 ,$6.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,$27.07 ,$27.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,$8.07 ,$8.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,$8.09 ,$8.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,$7.71 ,$7.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,$8.41 ,$8.41 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,$20.46 ,$20.46 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,$10.32 ,$10.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,$10.32 ,$10.32 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,$15.39 ,$15.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,$19.60 ,$19.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,$10.80 ,$10.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,$14.61 ,$14.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,$5.57 ,$5.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,$12.52 ,$12.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,$7.74 ,$7.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,$115.36 ,$115.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,$7.74 ,$7.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,$11.30 ,$11.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,$4.31 ,$4.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,$5.88 ,$5.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,$8.90 ,$8.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,$4.75 ,$4.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,$7.48 ,$7.48 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,$4.75 ,$4.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,$40.17 ,$40.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,$6.64 ,$6.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,$7.31 ,$7.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,$15.02 ,$15.02 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,$5.39 ,$5.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,$5.99 ,$5.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,$17.98 ,$17.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,$5.82 ,$5.82 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,$19.74 ,$19.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,$19.56 ,$19.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,$26.07 ,$26.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,$20.20 ,$20.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,$19.56 ,$19.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,$33.86 ,$33.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,$14.43 ,$14.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,$13.61 ,$13.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,$12.25 ,$12.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,$16.07 ,$16.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,$15.60 ,$15.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,$16.43 ,$16.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,$60.80 ,$60.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,$12.18 ,$12.18 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,$16.10 ,$16.10 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,$15.00 ,$15.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,$13.82 ,$13.82 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,$12.66 ,$12.66 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,$14.38 ,$14.38 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,$10.33 ,$10.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,$10.33 ,$10.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,$24.08 ,$24.08 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,$24.06 ,$24.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,$21.90 ,$21.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,$14.13 ,$14.13 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,$13.91 ,$13.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,$16.81 ,$16.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,$10.51 ,$10.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,$55.74 ,$55.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,$416.78 ,$416.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,$22.75 ,$22.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,$53.47 ,$53.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,$37.27 ,$37.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,$30.03 ,$30.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,$51.31 ,$51.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,$95.80 ,$95.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,$29.22 ,$29.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,$128.29 ,$128.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,$262.99 ,$262.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,$416.78 ,$416.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,$31.22 ,$31.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,$29.80 ,$29.80 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,$39.26 ,$39.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,$58.00 ,$58.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,$21.92 ,$21.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,$85.10 ,$85.10 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,$21.92 ,$21.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,$58.62 ,$58.62 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,$48.24 ,$48.24 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,$26.88 ,$26.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,$41.68 ,$41.68 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,$27.29 ,$27.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,$302.62 ,$302.62 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,$26.88 ,$26.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,$40.55 ,$40.55 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,$142.63 ,$142.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,$218.06 ,$218.06 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,$416.78 ,$416.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,$70.20 ,$70.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,$51.31 ,$51.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,$30.03 ,$30.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,$43.67 ,$43.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,$70.20 ,$70.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,$12.73 ,$12.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,$16.55 ,$16.55 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,$32.77 ,$32.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,$13.10 ,$13.10 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,$15.29 ,$15.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,$21.76 ,$21.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,$35.29 ,$35.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,$24.56 ,$24.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,$16.53 ,$16.53 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,$16.07 ,$16.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,$130.35 ,$130.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,$257.45 ,$257.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,$257.45 ,$257.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,$488.66 ,$488.66 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,$26.07 ,$26.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,$12.22 ,$12.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,$128.73 ,$128.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,$257.45 ,$257.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,$257.45 ,$257.45 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,$17.98 ,$17.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,$7.99 ,$7.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,$20.26 ,$20.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,$23.04 ,$23.04 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,$50.56 ,$50.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,$27.64 ,$27.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,$24.03 ,$24.03 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,$14.65 ,$14.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,$42.22 ,$42.22 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,$25.37 ,$25.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,$26.61 ,$26.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,$116.49 ,$116.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,$140.73 ,$140.73 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,$150.30 ,$150.30 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,$143.75 ,$143.75 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,$147.52 ,$147.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,$13.07 ,$13.07 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,$12.09 ,$12.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,$173.17 ,$173.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,$173.17 ,$173.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,$173.17 ,$173.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,$264.34 ,$264.34 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,$125.49 ,$125.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,$150.29 ,$150.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,$144.61 ,$144.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,$188.57 ,$188.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,$173.66 ,$173.66 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,$21.42 ,$21.42 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,$40.70 ,$40.70 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,$34.81 ,$34.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,$42.38 ,$42.38 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,$51.19 ,$51.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,$33.47 ,$33.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,$68.60 ,$68.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,$26.91 ,$26.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,$34.43 ,$34.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,$5.02 ,$5.02 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,$5.02 ,$5.02 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,$9.37 ,$9.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,$9.37 ,$9.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,$4.72 ,$4.72 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,$5.60 ,$5.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,$7.33 ,$7.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,$5.88 ,$5.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,$4.85 ,$4.85 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,$5.79 ,$5.79 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,$9.84 ,$9.84 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,$8.61 ,$8.61 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,$12.31 ,$12.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,$12.05 ,$12.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,$15.50 ,$15.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,$10.67 ,$10.67 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,$19.59 ,$19.59 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,$10.38 ,$10.38 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,$19.59 ,$19.59 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,$720.00 ,$720.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,$503.40 ,$503.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,$25.00 ,$25.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,$503.40 ,$503.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,$950.00 ,$950.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,$79.00 ,$79.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,$150.00 ,$150.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,$375.00 ,$375.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,$597.91 ,$597.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,$107.00 ,$107.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,$427.26 ,$427.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"$2,515.60 ","$2,515.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"$2,515.60 ","$2,515.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,$176.19 ,$176.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"$2,515.60 ","$2,515.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,$163.96 ,$163.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,$91.66 ,$91.66 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"$3,002.09 ","$3,002.09 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"$3,675.00 ","$3,675.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"$1,950.00 ","$1,950.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,$248.51 ,$248.51 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,$34.19 ,$34.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,$85.77 ,$85.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"$3,600.00 ","$3,600.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,$121.91 ,$121.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,$742.27 ,$742.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,$134.13 ,$134.13 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,$349.62 ,$349.62 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,$466.17 ,$466.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,$540.99 ,$540.99 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"$4,780.00 ","$4,780.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"$3,500.00 ","$3,500.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,$29.60 ,$29.60 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,$13.74 ,$13.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,$409.90 ,$409.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,$17.21 ,$17.21 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,$17.21 ,$17.21 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,$14.86 ,$14.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,$14.86 ,$14.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,$407.43 ,$407.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"$2,919.60 ","$2,919.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,$407.43 ,$407.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"$2,916.60 ","$2,916.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,$193.71 ,$193.71 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,$33.86 ,$33.86 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"$2,030.00 ","$2,030.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,$148.96 ,$148.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"$3,240.00 ","$3,240.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"$2,515.60 ","$2,515.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,$322.96 ,$322.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,$322.96 ,$322.96 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,$759.05 ,$759.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,$25.10 ,$25.10 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,$380.72 ,$380.72 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,$750.00 ,$750.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,$31.33 ,$31.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,$18.09 ,$18.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,$15.29 ,$15.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"$1,897.00 ","$1,897.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,$142.63 ,$142.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,$380.00 ,$380.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,$676.37 ,$676.37 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,$43.43 ,$43.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"$3,520.00 ","$3,520.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,$246.92 ,$246.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,$167.35 ,$167.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,$720.00 ,$720.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,$200.00 ,$200.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"$3,159.42 ","$3,159.42 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"$3,159.42 ","$3,159.42 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"$1,755.00 ","$1,755.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"$2,488.00 ","$2,488.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,$62.14 ,$62.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"$7,582.20 ","$7,582.20 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,$771.98 ,$771.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,$363.04 ,$363.04 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,$950.00 ,$950.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,$874.49 ,$874.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"$2,513.25 ","$2,513.25 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,$142.63 ,$142.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,$682.29 ,$682.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,$356.13 ,$356.13 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"$1,938.01 ","$1,938.01 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,$275.35 ,$275.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,$246.92 ,$246.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,$840.65 ,$840.65 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"$2,753.25 ","$2,753.25 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,$83.76 ,$83.76 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"$2,510.21 ","$2,510.21 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,$509.20 ,$509.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,$526.23 ,$526.23 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,$357.63 ,$357.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,$710.00 ,$710.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,$741.64 ,$741.64 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,$690.29 ,$690.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,$748.39 ,$748.39 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,$700.56 ,$700.56 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,$407.43 ,$407.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,$468.33 ,$468.33 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,$482.14 ,$482.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,$503.40 ,$503.40 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,$7.52 ,$7.52 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,$466.17 ,$466.17 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"$1,755.00 ","$1,755.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"$3,030.00 ","$3,030.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,$64.19 ,$64.19 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,$416.78 ,$416.78 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"$2,919.60 ","$2,919.60 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,$47.00 ,$47.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,$18.63 ,$18.63 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"$2,279.00 ","$2,279.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"$3,500.00 ","$3,500.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"$5,000.00 ","$5,000.00 ",,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,$6.50 ,$6.50 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,$19.31 ,$19.31 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,$20.26 ,$20.26 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,$27.05 ,$27.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,$43.97 ,$43.97 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,$26.49 ,$26.49 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,$31.94 ,$31.94 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,$7.77 ,$7.77 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,$18.05 ,$18.05 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,$19.57 ,$19.57 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,$18.29 ,$18.29 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,$5.00 ,$5.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,$46.35 ,$46.35 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,$24.08 ,$24.08 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,$156.59 ,$156.59 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,$198.74 ,$198.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,$246.92 ,$246.92 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,$28.27 ,$28.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,$62.14 ,$62.14 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,$3.00 ,$3.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,$5.83 ,$5.83 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,$9.74 ,$9.74 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,$25.00 ,$25.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,$75.00 ,$75.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,$75.00 ,$75.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,$25.00 ,$25.00 ,,,,,,,,,,,,
Health Alliance MCR Adv HMO/POS,,,,All Other,Straight Discount,30.00%,OP,,,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,ExceptPatType,14,,Swing Bed,Per Diem,"$4,334.63 ",IP,$640.00 ,"4,816.25",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","462,611.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","239,521.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","305,688.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","190,760.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-005,LIVER TRANSPLANT WITH MCC OR INTESTINAL TRANSPLANT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","163,760.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-006,LIVER TRANSPLANT WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","75,142.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-007,LUNG TRANSPLANT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","185,280.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","86,932.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-010,PANCREAS TRANSPLANT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","57,920.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","80,342.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","61,324.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-013,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","43,580.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","170,832.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","107,780.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","77,691.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","599,201.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","106,875.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","165,392.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","120,696.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","77,484.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-023,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITH MCC OR CHEMOTHERAPY IMPLANT OR EPILEPSY WITH NEUROSTIMULATOR,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","90,750.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","63,024.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","71,958.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-026,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","48,992.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,228.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","93,169.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","52,748.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,708.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","69,947.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","35,464.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,555.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-034,CAROTID ARTERY STENT PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","63,649.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,435.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,636.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","52,441.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,540.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,225.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","61,836.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-041,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH CC OR PERIPHERAL NEUROSTIMULATOR,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,595.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-042,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,419.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,656.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,182.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,892.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,713.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","35,124.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,280.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,804.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,036.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,683.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-061,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","46,259.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-062,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,812.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,355.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,702.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH CC OR TPA IN 24 HOURS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,320.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,385.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,812.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,222.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,593.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,873.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,188.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,347.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,246.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,304.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,032.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,758.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,526.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,198.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,660.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-080,NONTRAUMATIC STUPOR AND COMA WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,526.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-081,NONTRAUMATIC STUPOR AND COMA WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,371.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","36,222.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,504.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,489.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","36,987.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,392.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,817.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-088,CONCUSSION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,283.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-089,CONCUSSION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,016.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,673.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,412.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,822.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,515.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","58,206.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,116.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,323.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","60,166.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,800.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,430.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-100,SEIZURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,022.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-101,SEIZURES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,214.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-102,HEADACHES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,449.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-103,HEADACHES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,272.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","35,110.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,161.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,305.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-116,INTRAOCULAR PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,123.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-117,INTRAOCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,659.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,049.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,328.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,268.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,432.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,392.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","34,296.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,088.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,155.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,704.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-139,SALIVARY GLAND PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,745.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","63,646.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","35,297.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,681.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","47,676.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-144,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,184.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-145,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,593.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","32,657.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,817.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-148,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,592.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-149,DYSEQUILIBRIUM,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,792.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-150,EPISTAXIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,240.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-151,EPISTAXIS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,814.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,288.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,411.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,748.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,552.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-156,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,534.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,219.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,403.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,609.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","80,108.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","42,489.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,665.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-166,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","59,576.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,099.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,670.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,736.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,204.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-177,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,585.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,324.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,963.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,838.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,921.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,672.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,942.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,654.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-185,MAJOR CHEST TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,398.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,700.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-187,PLEURAL EFFUSION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,526.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,672.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,617.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,001.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,148.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,129.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-193,SIMPLE PNEUMONIA AND PLEURISY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,992.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,822.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,652.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,817.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,112.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,894.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-199,PNEUMOTHORAX WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,640.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-200,PNEUMOTHORAX WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,224.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,353.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,472.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,312.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,697.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,956.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,176.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT >96 HOURS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","91,777.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,716.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","168,934.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","160,628.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","103,736.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","97,748.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","128,921.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","86,484.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","73,278.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","127,216.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","92,777.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","120,305.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","89,884.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","105,040.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","83,393.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","85,284.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","55,059.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-231,CORONARY BYPASS WITH PTCA WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","139,454.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-232,CORONARY BYPASS WITH PTCA WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","95,260.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","126,756.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","85,376.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","97,665.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","65,552.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","77,056.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","44,620.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,478.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","59,641.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,296.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,012.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-245,AICD GENERATOR PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","86,684.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","49,988.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,571.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","50,595.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,979.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,348.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-251,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,534.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-252,OTHER VASCULAR PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","53,211.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","42,457.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,054.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,564.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,307.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,643.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","50,689.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,427.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","57,076.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,902.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,299.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-263,VEIN LIGATION AND STRIPPING,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,011.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","52,057.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-265,AICD LEAD PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","53,848.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","112,766.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","89,568.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","111,412.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","69,041.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","82,992.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","57,046.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","43,012.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","61,227.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","52,585.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,710.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,889.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,617.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,835.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,574.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","7,915.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","34,180.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,841.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-288,ACUTE AND SUBACUTE ENDOCARDITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","42,966.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,297.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,430.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,292.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,816.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","9,438.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,524.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,745.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-296,CARDIAC ARREST- UNEXPLAINED WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,523.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,312.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","7,820.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,521.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,700.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,889.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,516.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,841.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-304,HYPERTENSION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,552.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-305,HYPERTENSION WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,838.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,118.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,926.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,214.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,008.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-310,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","8,947.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-311,ANGINA PECTORIS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,176.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-312,SYNCOPE AND COLLAPSE,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,419.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-313,CHEST PAIN,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,542.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,355.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,574.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,574.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","69,086.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","38,489.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","85,060.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","41,035.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,670.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","78,179.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,788.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,368.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-332,RECTAL RESECTION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","66,584.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-333,RECTAL RESECTION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","34,260.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,737.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","62,616.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","36,660.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,196.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","44,756.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-339,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,158.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-340,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,652.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,158.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,926.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,737.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","45,094.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,260.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,406.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","39,435.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,569.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,668.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","39,276.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,883.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,670.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","48,398.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,556.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,763.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","68,924.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","36,296.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,585.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,185.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,235.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,969.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,699.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,468.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,913.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,179.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,321.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,382.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,819.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,896.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,195.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,185.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,948.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,297.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,001.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,284.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,956.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-386,INFLAMMATORY BOWEL DISEASE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,921.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-387,INFLAMMATORY BOWEL DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,435.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,233.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,171.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","9,329.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,987.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,252.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,579.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,054.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,424.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","91,801.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-406,PANCREAS- LIVER AND SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","46,094.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-407,PANCREAS- LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,888.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","60,046.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,862.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-410,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,092.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-411,CHOLECYSTECTOMY WITH C.D.E. WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","60,056.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","36,440.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,694.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","58,052.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","32,507.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,756.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","38,788.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,024.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,044.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","56,264.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,520.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,257.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","66,974.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","36,545.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,683.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,092.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,478.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","9,931.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,054.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,944.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,334.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,564.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,523.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","9,700.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,072.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,880.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,611.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,745.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,240.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-446,DISORDERS OF THE BILIARY TRACT WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,065.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-453,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","147,008.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","97,489.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","76,500.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","137,600.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","103,934.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","80,121.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","107,736.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","62,891.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","97,307.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","50,262.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","85,924.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","47,614.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,505.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","85,531.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","57,240.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","44,838.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","49,374.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,404.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","80,315.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","48,859.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,624.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","65,217.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","35,140.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,564.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","53,742.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,734.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,952.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","48,412.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,537.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-482,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,332.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-483,MAJOR JOINT OR LIMB REATTACHMENT PROCEDURES OF UPPER EXTREMITIES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","38,171.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","54,553.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","34,390.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,243.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,611.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,771.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","55,520.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,212.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,627.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","58,270.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,782.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,224.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","41,339.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,184.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","51,032.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,065.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,324.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-503,FOOT PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","42,249.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-504,FOOT PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,400.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,400.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,737.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","32,974.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,555.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-509,ARTHROSCOPY,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,984.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","43,899.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,478.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,872.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,152.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-514,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,985.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-515,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","50,249.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,404.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,371.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","57,390.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,360.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,692.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","49,059.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","35,030.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,659.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,643.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,724.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,347.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,966.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,571.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-539,OSTEOMYELITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,163.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-540,OSTEOMYELITIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,825.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,491.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,947.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,723.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,443.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,049.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,328.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,337.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","32,812.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-549,SEPTIC ARTHRITIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,998.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-550,SEPTIC ARTHRITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,062.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,038.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,094.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,344.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,680.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,896.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,939.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-557,TENDONITIS- MYOSITIS AND BURSITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,385.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,782.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,844.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,216.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,678.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,588.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,955.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,377.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-565,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,148.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,030.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","45,467.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,166.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,670.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","88,625.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","51,944.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,211.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","81,019.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,793.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,523.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","50,318.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,660.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,028.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,289.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-583,MASTECTOMY FOR MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,664.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,387.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,833.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-592,SKIN ULCERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,108.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-593,SKIN ULCERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,249.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,056.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","32,264.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-596,MAJOR SKIN DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,915.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-597,MALIGNANT BREAST DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,304.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,806.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,742.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,950.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,988.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-602,CELLULITIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,200.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-603,CELLULITIS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,657.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-604,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,646.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,462.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,193.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,251.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","38,235.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-615,ADRENAL AND PITUITARY PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,200.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","63,459.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","32,476.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,851.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","48,987.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,203.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,553.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","57,838.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,944.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,582.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","45,443.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-626,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,446.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-627,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,924.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","58,870.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,524.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-630,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,548.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-637,DIABETES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,025.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-638,DIABETES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,070.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-639,DIABETES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","9,753.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,692.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,067.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,636.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,683.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,316.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,297.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","72,331.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","59,174.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-652,KIDNEY TRANSPLANT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","50,961.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","87,347.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","46,444.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,284.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","52,560.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,955.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,246.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","42,662.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-660,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,089.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,019.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","46,996.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,592.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,940.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-665,PROSTATECTOMY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","48,667.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-666,PROSTATECTOMY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,835.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-667,PROSTATECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,960.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-668,TRANSURETHRAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","44,900.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,016.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,656.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,500.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,406.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","55,492.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","38,131.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,075.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-682,RENAL FAILURE WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,563.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-683,RENAL FAILURE WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,068.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","9,726.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,004.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,801.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,972.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,827.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,704.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-693,URINARY STONES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,368.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-694,URINARY STONES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,339.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,203.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,070.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-697,URETHRAL STRICTURE,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,988.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,769.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,432.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,944.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,755.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,859.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-709,PENIS PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,054.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-710,PENIS PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,625.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","34,105.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,960.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,894.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,860.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","32,345.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,412.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,809.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,753.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,401.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,470.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,369.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,568.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,915.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,736.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,891.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,120.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","9,102.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-734,PELVIC EVISCERATION- RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","35,588.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-735,PELVIC EVISCERATION- RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,617.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","68,171.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","32,929.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-738,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,614.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-739,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","61,184.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,825.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,478.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,489.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,124.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,726.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,720.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-746,VAGINA- CERVIX AND VULVA PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,784.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,025.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,561.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","43,420.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,420.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,219.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,068.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-756,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,694.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-757,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,395.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,515.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,934.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,721.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","9,452.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-768,VAGINAL DELIVERY WITH O.R. PROCEDURES EXCEPT STERILIZATION AND/OR D&C,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,713.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,881.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,236.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,392.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-779,ABORTION WITHOUT D&C,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,944.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,998.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,534.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,668.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,510.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,030.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,198.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Acute Care,Per Diem,"$4,822.58 ",IP,$600.00 ,"27,520.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Acute Care,Per Diem,"$4,822.58 ",IP,$600.00 ,"90,753.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-791,PREMATURITY WITH MAJOR PROBLEMS,Acute Care,Per Diem,"$4,822.58 ",IP,$600.00 ,"61,980.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-792,PREMATURITY WITHOUT MAJOR PROBLEMS,Acute Care,Per Diem,"$4,822.58 ",IP,$600.00 ,"37,398.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Acute Care,Per Diem,"$4,822.58 ",IP,$600.00 ,"63,667.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Acute Care,Per Diem,"$4,822.58 ",IP,$600.00 ,"22,534.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-795,NORMAL NEWBORN,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","5,358.42",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,132.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,710.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,240.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-799,SPLENECTOMY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","82,358.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-800,SPLENECTOMY WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","47,262.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,944.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","59,387.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,184.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,854.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,478.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,753.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,276.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","34,972.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,574.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,387.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,068.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,084.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-813,COAGULATION DISORDERS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,721.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,267.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,894.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-816,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,577.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","36,908.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,756.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,795.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","91,067.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","34,483.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,024.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","72,028.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","37,830.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","22,424.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","80,712.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,009.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,784.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","51,334.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,712.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,948.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,452.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","8,592.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-834,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","96,835.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,819.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,776.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","91,188.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","36,163.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,795.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","51,528.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-841,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,945.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,552.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,521.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,947.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,582.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","42,766.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,377.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,516.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-849,RADIOTHERAPY,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","39,897.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","79,484.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,955.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","24,316.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","74,622.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","33,638.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,753.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-862,POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,347.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-863,POSTOPERATIVE AND POST-TRAUMATIC INFECTIONS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,182.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,024.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-865,VIRAL ILLNESS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,644.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,424.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","35,793.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,056.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,656.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","103,024.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,955.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,420.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","52,288.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Acute Care,Per Diem,"$4,822.58 ",IP,$550.00 ,"13,832.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-881,DEPRESSIVE NEUROSES,Acute Care,Per Diem,"$4,822.58 ",IP,$550.00 ,"12,832.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Acute Care,Per Diem,"$4,822.58 ",IP,$550.00 ,"13,177.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-883,DISORDERS OF PERSONALITY AND IMPULSE CONTROL,Acute Care,Per Diem,"$4,822.58 ",IP,$550.00 ,"25,308.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Acute Care,Per Diem,"$4,822.58 ",IP,$550.00 ,"23,156.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-885,PSYCHOSES,Acute Care,Per Diem,"$4,822.58 ",IP,$550.00 ,"19,830.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Acute Care,Per Diem,"$4,822.58 ",IP,$550.00 ,"19,579.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Acute Care,Per Diem,"$4,822.58 ",IP,$550.00 ,"17,276.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","8,784.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,587.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-896,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,484.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-897,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","13,232.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","68,299.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,428.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,164.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","59,632.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,400.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","28,860.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","63,171.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","32,806.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,936.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,217.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,190.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,192.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","10,534.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-917,POISONING AND TOXIC EFFECTS OF DRUGS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,656.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-918,POISONING AND TOXIC EFFECTS OF DRUGS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,665.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","29,505.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","16,393.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,166.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","25,411.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,036.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","337,460.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","104,505.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","48,222.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","36,206.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","31,054.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-935,NON-EXTENSIVE BURNS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,926.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","53,993.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","35,534.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-941,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","30,769.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-945,REHABILITATION WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,710.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","18,019.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","19,104.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","12,593.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-949,AFTERCARE WITH CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,758.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","11,843.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","8,953.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","100,628.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","61,600.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","118,734.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","67,291.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","43,777.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","43,678.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","23,868.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","14,600.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","93,630.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","47,819.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","43,048.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","20,513.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","15,193.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","21,188.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","73,832.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","40,585.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","26,436.80",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","52,414.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","27,302.40",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","17,977.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","5,358.42",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,DRG,MS-999,UNGROUPABLE,Acute Care,Per Diem,"$4,822.58 ",IP,"$1,275.00 ","5,358.42",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0051U,Rx mntr lc-ms/ms ur/bld 31,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0224U,Antibody sars-cov-2 titer(s),Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0226U,Svnt sarscov2 elisa plsm srm,Lab Services,Per Unit,$42.28 ,OP,42.28,42.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0240U,Nfct ds vir resp rna 3 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0241U,Nfct ds vir resp rna 4 trgt,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,94.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,8.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,7.01,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,47.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,8.68,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,47.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,16.38,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,13.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,16.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80189,Drug assay itraconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,60,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,16.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,16.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,11.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,12.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,17.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,32.62,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,86.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,78.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,125.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,80.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,801.62,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,51.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,55.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,209.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,43.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,579.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,161.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,46.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,50.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,148.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,66.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,129.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,165.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,285.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,103,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,91.16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,50.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,67.21,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,4.02,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,3.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,3.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,2.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,2.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,4.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,3.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81228,Cytog alys chrml abnr cgh,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81229,Cytog alys chrml abnr snpcgh,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,260.5,260.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,897,897,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,68.92,68.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,54.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,"1,487.37","1,487.37",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,55.54,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,153.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,69.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,16.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,38.62,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,25.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,7.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,6.23,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,30,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,40.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,16.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,25.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,13.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,22.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,19.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,9.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,6.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,25.55,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,20.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,21.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,18.97,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,15.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,16.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,17.12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,26.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,4.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,4.38,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,5.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,15.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,23.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,26.79,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,13.68,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,6.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,4.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,12.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,14.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,18.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,9.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,27.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,29.08,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,25.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,14.12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,12.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,4.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,4.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,7.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,20.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,20.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,27.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,18.68,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,12.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,22.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,16.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,4.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,24.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,6.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,11.55,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,11.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,5.12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,9.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,25.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,22.23,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,38.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82656,El-1 fecal qual/semiq,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,22.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,61.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,18.79,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,32.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,21.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,24.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,24.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,14.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,26.24,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,22.97,22.97,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,19.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,13.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,18.54,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,14.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,17.34,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,11.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,21.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,9.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,16.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,8.02,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,78.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,17.69,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,17.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,14.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,17.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,5.04,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,3.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,9.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,13.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,15.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,16.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,18.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,16.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,12.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,26.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,7.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,20.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,21.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,6.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,8.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,29.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,17.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,22.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,27.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,22.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,24.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,18.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,11.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,19.82,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,8.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,8.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,12.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,6.04,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,12.79,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,19.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,20.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,11.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,19.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,46.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,12.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,10.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,6.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,26.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,16.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,17.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,12.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,13.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,24.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,27.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,23.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,21.21,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,29.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,14.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,41.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,3.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,7.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,8.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,16.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,10.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,4.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,8.44,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,14.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,4.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,4.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,14.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,21.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,21.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,20.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,22.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,20.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,19.38,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,5.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,17.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,29.21,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,14.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,26.69,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,28.1,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,14.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,87.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,64.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,71.23,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,36.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,25.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,21.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,25.21,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,4.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,5.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,4.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,21.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,18.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,8.1,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,5.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,25.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,21.23,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,16.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,6.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,9.02,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,5.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,12.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,15.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,12.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,9.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,10.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,10.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,5.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,5.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,5.08,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,4.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,17.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,13.72,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,17.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,12.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,11.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,12.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,4.82,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,3.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,5.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,3.02,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,2.54,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,4.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,35.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,11.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,20.37,20.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,12.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,20.42,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,19.04,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,9.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,11.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,10.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,13.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,4.28,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,4.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,80.46,80.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,12.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,15.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,4.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,9.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,8.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,11.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,6.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,18.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,24.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,4.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,3.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,9.58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,9.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,2.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,5.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,6.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,9.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,11.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,7.82,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,5.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,18.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,11.16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,8.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,20.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,10.01,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,25.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,14.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,23.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86328,Ia nfct ab sarscov2 covid19,Lab Services,Per Unit,$45.23 ,OP,45.23,45.23,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,24.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,22.34,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,29.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,15.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,21.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,23.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,10.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,49.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,46.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,77.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,14.55,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,16.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,11.54,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,10.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86408,Neutrlzg antb sarscov2 scr,Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86409,Neutrlzg antb sarscov2 titer,Lab Services,Per Unit,$105.33 ,OP,105.33,105.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86413,Sars-cov-2 antb quantitative,Lab Services,Per Unit,$51.43 ,OP,51.43,51.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,6.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,5.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,61.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,4.4,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,13.38,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,11.82,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,12.68,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,11.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,12.12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,15.21,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,13.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,18.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,14.16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,13.01,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,9.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,17.16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,13.79,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,8.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,13.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,13.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,11.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,13.55,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,16.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,15.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,18.23,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86769,Sars-cov-2 covid-19 antibody,Lab Services,Per Unit,$42.13 ,OP,42.13,42.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,24.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,14.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,15.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,14.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,189.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,47.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,78.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,29.68,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,106.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,36.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,8.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,16.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,6.68,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,8.62,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,6.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,27.07,27.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,8.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,20.46,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,15.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,19.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,10.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,14.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,11.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,8.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,7.48,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,40.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,15.02,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,5.39,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,19.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,20.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,15.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,16.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,60.8,60.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,12.18,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,16.1,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87320,Chlmyd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,13.82,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,14.38,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87341,Hep b surface ag neutrlzj ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87389,Hiv-1 ag w/hiv-1&-2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,21.9,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,14.13,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,13.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87426,Sarscov coronavirus ag ia,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87428,Sarscov & inf vir a&b ag ia,Lab Services,Per Unit,$63.59 ,OP,63.59,63.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,16.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,10.51,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,55.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87485,Chlmyd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87486,Chlmyd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87487,Chlmyd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87490,Chlmyd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,22.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87491,Chlmyd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87492,Chlmyd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,53.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,31.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,29.8,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,85.1,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,58.62,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,48.24,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,41.68,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,27.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,302.62,302.62,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,40.55,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87635,Sars-cov-2 covid-19 amp prb,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87636,Sarscov2 & inf a&b amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,43.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,12.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,16.55,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87806,Hiv ag w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,32.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,13.1,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,21.76,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87810,Chlmyd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,35.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87811,Sars-cov-2 covid19 w/optic,Lab Services,Per Unit,$41.38 ,OP,41.38,41.38,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,24.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,16.53,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,130.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,12.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,7.99,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,23.04,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,50.56,50.56,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,27.64,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,24.03,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,14.65,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,42.22,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,25.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,26.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,116.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,140.73,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,150.3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,143.75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,147.52,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,13.07,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,264.34,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,125.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,150.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,144.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,188.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,173.66,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,21.42,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,40.7,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,34.81,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,42.38,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,51.19,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,33.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,26.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,34.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,4.72,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,5.6,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,7.33,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,4.85,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,5.79,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,9.84,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,12.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,10.38,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,6.5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,19.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,27.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,43.97,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,26.49,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,31.94,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,5.83,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,U0001,2019-ncov diagnostic p,Lab Services,Per Unit,$35.91 ,OP,35.91,35.91,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,U0002,Covid-19 lab test non-cdc,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Health Alliance MCR Adv HPNC,,,,All Other,Straight Discount,30.00%,OP,,,,,,,,,,,,,,
Health Alliance Public Exchange,ExceptPatType,14,,Swing Bed,Per Diem,"$6,338.19 ",IP,$640.00 ,"$4,816.25 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$463,441.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$254,896.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$303,857.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$189,792.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$163,572.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$75,067.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-007,LUNG TRANSPLANT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$185,188.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$86,828.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-010,PANCREAS TRANSPLANT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$57,883.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$80,262.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$61,310.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-013,TRACHEOSTOMY FOR FACE - MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$43,528.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$204,460.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$107,619.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$77,283.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$597,264.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$106,590.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$165,121.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$120,505.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$77,753.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$90,596.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$62,920.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$71,867.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$48,928.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,188.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$93,120.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$52,720.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$37,713.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$69,857.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$35,395.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,531.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$63,593.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$37,393.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,619.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$52,395.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,516.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,224.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$63,324.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$37,617.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,158.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,521.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,177.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,852.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,694.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$34,996.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,227.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,787.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,024.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,649.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-061,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$46,211.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-062,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,795.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,358.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,608.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,291.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,374.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,793.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,577.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,822.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,172.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,339.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,190.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,294.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,016.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,694.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,184.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,628.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,472.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,352.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,129.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,467.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,467.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,902.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,366.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,801.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-088,CONCUSSION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,348.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-089,CONCUSSION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,979.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,676.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,382.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,777.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,500.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$58,129.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,128.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$37,304.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$60,041.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,774.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,356.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-100,SEIZURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,977.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-101,SEIZURES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,192.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-102,HEADACHES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,427.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-103,HEADACHES W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,251.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$35,068.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,128.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,252.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,035.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,622.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,019.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,300.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,244.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,380.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,366.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$34,249.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,088.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,497.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,489.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-139,SALIVARY GLAND PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,628.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$63,689.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$35,320.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,740.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$47,420.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,008.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-145,OTHER EAR - NOSE - MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,416.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,529.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,817.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,580.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-149,DYSEQUILIBRIUM,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,768.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-150,EPISTAXIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,195.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-151,EPISTAXIS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,792.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,230.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,369.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,680.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,508.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-156,OTHER EAR - NOSE - MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,521.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,158.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,225.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,492.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$79,377.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$42,227.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,617.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$60,660.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,790.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,905.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,707.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,187.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,524.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,294.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,937.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,804.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,934.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,600.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,889.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,630.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,377.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,691.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-187,PLEURAL EFFUSION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,515.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,649.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,596.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,982.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,129.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,118.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,971.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,808.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,640.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,777.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,089.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,876.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-199,PNEUMOTHORAX WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,601.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-200,PNEUMOTHORAX WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,200.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,352.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,449.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,288.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,680.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,916.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,147.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$91,622.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,676.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$178,526.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$166,881.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$103,884.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$82,291.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$128,881.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$86,398.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$72,836.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$134,737.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$99,393.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$117,795.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$90,028.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$105,788.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$84,030.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$99,444.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$63,808.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$135,843.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$94,372.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$124,683.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$85,078.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$96,483.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$65,292.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$76,939.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$44,638.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,462.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$59,560.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,521.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,051.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-245,AICD GENERATOR PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$86,624.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$50,011.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,811.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$50,782.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,068.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,364.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,556.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$53,131.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$42,459.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,952.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,688.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,289.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,576.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$51,220.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,923.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$57,347.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,860.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,329.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-263,VEIN LIGATION AND STRIPPING,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,884.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$51,964.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-265,AICD LEAD PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$53,803.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$113,555.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$89,614.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$111,273.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$69,033.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$82,905.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$57,033.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$43,020.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$61,395.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$52,566.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,019.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,913.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,608.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,833.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,747.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$7,942.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$35,425.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI - WITH CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,400.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$42,896.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,281.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,377.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,454.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,321.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,441.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,513.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,700.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,516.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,273.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$7,811.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,502.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,675.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,880.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,496.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,822.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-304,HYPERTENSION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,529.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-305,HYPERTENSION WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,816.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,059.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,894.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,188.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,990.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$8,934.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-311,ANGINA PECTORIS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,152.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-312,SYNCOPE AND COLLAPSE,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-313,CHEST PAIN,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,532.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,334.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,603.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,992.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$69,052.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$39,099.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$86,043.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$41,753.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,648.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$77,604.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,624.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,361.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-332,RECTAL RESECTION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$66,555.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-333,RECTAL RESECTION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$34,256.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,747.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$62,246.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,526.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,121.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$44,780.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,120.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,654.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$37,059.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,929.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,750.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$44,814.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,243.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,400.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$39,385.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,478.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,668.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$39,238.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,846.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,648.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$48,132.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,528.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,747.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$68,662.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,059.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,424.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,076.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,961.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,652.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,441.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,896.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,086.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,278.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,323.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,782.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,891.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,193.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,129.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,955.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,292.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,974.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,278.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,905.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,896.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,416.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,188.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,148.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$9,321.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,910.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,230.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,457.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,017.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,395.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$91,688.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-406,PANCREAS - LIVER AND SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$46,032.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-407,PANCREAS - LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,856.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$59,992.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,828.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,051.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$60,038.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,411.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,702.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$58,008.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,510.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,755.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$38,776.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,009.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,043.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$56,225.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,542.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,222.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$66,864.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,505.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,692.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,113.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,456.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$9,913.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,044.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,923.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,312.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,540.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,510.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$9,694.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,139.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,905.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,604.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,700.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,059.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$147,097.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$97,569.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$76,656.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$137,569.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$104,032.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$80,278.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$107,708.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$62,923.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$97,219.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$50,307.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$85,846.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$47,592.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,497.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$85,520.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$57,219.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$44,864.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$49,350.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,398.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$80,268.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$48,851.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,643.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$65,164.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$35,097.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,556.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$53,710.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$37,710.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,948.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$48,392.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,528.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,348.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$38,180.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$54,521.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$34,374.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,244.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,593.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,771.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$55,491.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$37,203.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,630.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$58,147.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,769.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,339.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$41,348.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,179.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$50,462.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,920.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,292.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-503,FOOT PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$42,059.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-504,FOOT PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,611.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,356.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,624.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-509,ARTHROSCOPY,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,780.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$43,691.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,496.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,899.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,944.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-514,HAND OR WRIST PROCEDURES - EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,907.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$50,192.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,377.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,347.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$57,348.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,323.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,678.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$49,014.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$35,025.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,601.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,617.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,740.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,345.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,931.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,542.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-539,OSTEOMYELITIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,059.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-540,OSTEOMYELITIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,724.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,449.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,884.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,692.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,419.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$39,992.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,305.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,328.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,473.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-549,SEPTIC ARTHRITIS W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,950.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,123.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,969.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,072.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,292.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,646.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,804.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,900.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-557,TENDONITIS - MYOSITIS AND BURSITIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,302.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,732.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,886.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,222.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,528.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,932.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,220.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,100.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,024.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$45,380.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,124.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,641.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$88,596.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$51,944.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,184.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$80,961.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,758.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,515.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$46,844.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,649.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,158.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,265.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,665.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,284.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,876.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-592,SKIN ULCERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,987.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-593,SKIN ULCERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,188.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,099.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,193.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,827.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,187.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,779.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,739.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,931.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,001.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-602,CELLULITIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,985.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-603,CELLULITIS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,516.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-604,TRAUMA TO THE SKIN - SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,860.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,547.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,176.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,209.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$38,188.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,185.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$63,820.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,545.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,848.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$48,977.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,177.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,542.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$57,804.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE - NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,966.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,508.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$45,459.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-626,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,436.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-627,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,908.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$59,169.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$37,548.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,510.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-637,DIABETES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,995.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-638,DIABETES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,070.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-639,DIABETES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$9,748.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,644.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,048.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,600.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,612.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,292.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,284.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$72,209.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$59,097.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-652,KIDNEY TRANSPLANT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$50,910.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$87,187.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$46,403.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,281.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$52,507.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,945.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,265.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$42,636.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,094.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,030.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$46,876.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,518.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,947.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-665,PROSTATECTOMY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$48,587.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-666,PROSTATECTOMY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,748.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,918.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$44,081.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,624.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,427.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,414.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$55,409.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$38,086.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,032.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-682,RENAL FAILURE WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,523.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-683,RENAL FAILURE WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,049.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$9,720.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,971.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,764.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,964.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,780.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,675.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-693,URINARY STONES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,300.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-694,URINARY STONES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,668.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,180.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,035.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-697,URETHRAL STRICTURE,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,952.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,707.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,403.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,916.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,729.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,862.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,990.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,598.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$34,084.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,920.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,865.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,856.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,302.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,424.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,776.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,779.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,344.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,425.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,390.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,510.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,892.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,689.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,856.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,076.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$9,051.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-734,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$35,564.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-735,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,616.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$68,131.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,931.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,625.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$61,147.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,800.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,472.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,472.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,116.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,704.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,728.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-746,VAGINA - CERVIX AND VULVA PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,750.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,008.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,572.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$43,318.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,454.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,136.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,041.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,657.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,353.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,472.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,931.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,761.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$9,440.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,732.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,926.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,209.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,300.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-779,ABORTION WITHOUT D&C,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,646.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,963.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,518.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,644.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,457.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,003.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,193.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Acute Care,Per Diem,"$7,051.68 ",IP,$600.00 ,"$27,496.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Acute Care,Per Diem,"$7,051.68 ",IP,$600.00 ,"$90,673.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Acute Care,Per Diem,"$7,051.68 ",IP,$600.00 ,"$61,926.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Acute Care,Per Diem,"$7,051.68 ",IP,$600.00 ,"$37,364.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Acute Care,Per Diem,"$7,051.68 ",IP,$600.00 ,"$63,611.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Acute Care,Per Diem,"$7,051.68 ",IP,$600.00 ,"$22,515.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-795,NORMAL NEWBORN,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,086.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,718.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,236.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-799,SPLENECTOMY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$82,302.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-800,SPLENECTOMY WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$47,222.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,936.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$59,339.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,156.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,827.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,428.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,742.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,257.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$34,846.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,547.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,371.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,041.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,075.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-813,COAGULATION DISORDERS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$24,715.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,251.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,880.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,574.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,828.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,064.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,966.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$90,996.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$34,481.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,025.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$71,953.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$37,803.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$22,411.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$80,588.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$39,961.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,843.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$51,291.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,624.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,937.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,476.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$8,576.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$96,801.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,819.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,713.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$91,185.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,140.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,780.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$51,451.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,932.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,524.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,446.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,888.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,558.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$42,718.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,363.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,464.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-849,RADIOTHERAPY,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$39,800.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$79,113.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$33,510.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,920.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$72,731.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,555.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,574.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,060.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,638.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,000.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-865,VIRAL ILLNESS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,662.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$35,672.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,934.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,616.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$102,796.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,891.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,345.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$52,180.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Acute Care,Per Diem,"$7,051.68 ",IP,$550.00 ,"$13,817.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-881,DEPRESSIVE NEUROSES,Acute Care,Per Diem,"$7,051.68 ",IP,$550.00 ,"$12,822.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Acute Care,Per Diem,"$7,051.68 ",IP,$550.00 ,"$13,168.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Acute Care,Per Diem,"$7,051.68 ",IP,$550.00 ,"$25,252.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Acute Care,Per Diem,"$7,051.68 ",IP,$550.00 ,"$23,100.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-885,PSYCHOSES,Acute Care,Per Diem,"$7,051.68 ",IP,$550.00 ,"$19,793.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Acute Care,Per Diem,"$7,051.68 ",IP,$550.00 ,"$19,544.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Acute Care,Per Diem,"$7,051.68 ",IP,$550.00 ,"$17,259.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$8,760.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,472.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-896,ALCOHOL - DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,432.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$13,208.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$68,195.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,398.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,150.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$59,542.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,345.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$28,700.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$63,313.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$32,646.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,993.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,182.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$27,161.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$10,516.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,640.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$29,350.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$16,436.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,062.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$25,401.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,886.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$336,494.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$104,419.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$48,142.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$36,121.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$31,044.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-935,NON-EXTENSIVE BURNS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,932.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$54,179.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$35,481.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$30,795.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-945,REHABILITATION WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,755.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$18,035.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$19,041.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$12,569.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-949,AFTERCARE WITH CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,713.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$11,822.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$8,931.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$100,608.00 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$61,580.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$118,732.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$67,286.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$43,747.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$43,587.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$23,814.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$14,606.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$92,598.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$47,121.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$42,971.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$20,465.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$15,185.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$21,132.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$73,724.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$40,659.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,476.80 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$52,193.60 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$26,891.20 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$17,854.40 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Health Alliance Public Exchange,DRG,MS-999,UNGROUPABLE,Acute Care,Per Diem,"$7,051.68 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$463,441.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$254,896.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$303,857.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$189,792.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$163,572.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$75,067.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-007,LUNG TRANSPLANT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$185,188.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$86,828.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-010,PANCREAS TRANSPLANT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$57,883.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$80,262.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$61,310.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-013,TRACHEOSTOMY FOR FACE - MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$43,528.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$204,460.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$107,619.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$77,283.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$597,264.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$106,590.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$165,121.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$120,505.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$77,753.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$90,596.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$62,920.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$71,867.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$48,928.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,188.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$93,120.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$52,720.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$37,713.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$69,857.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$35,395.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,531.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$63,593.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$37,393.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,619.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$52,395.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,516.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,224.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$63,324.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$37,617.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,158.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,521.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,177.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,852.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,694.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$34,996.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,227.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,787.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,024.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,649.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-061,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$46,211.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-062,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,795.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,358.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,608.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,291.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,374.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,793.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,577.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,822.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,172.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,339.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,190.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,294.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,016.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,694.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,184.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,628.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,472.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,352.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,129.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,467.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,467.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,902.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,366.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,801.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-088,CONCUSSION WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,348.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-089,CONCUSSION WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,979.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,676.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,382.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,777.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,500.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$58,129.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,128.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$37,304.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$60,041.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,774.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,356.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-100,SEIZURES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,977.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-101,SEIZURES WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,192.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-102,HEADACHES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,427.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-103,HEADACHES W/O MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,251.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$35,068.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,128.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,252.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,035.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,622.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,019.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,300.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,244.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,380.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,366.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$34,249.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,088.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,497.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,489.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-139,SALIVARY GLAND PROCEDURES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,628.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$63,689.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$35,320.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,740.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$47,420.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,008.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-145,OTHER EAR - NOSE - MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,416.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,529.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,817.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,580.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-149,DYSEQUILIBRIUM,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,768.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-150,EPISTAXIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,195.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-151,EPISTAXIS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,792.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,230.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,369.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,680.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,508.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-156,OTHER EAR - NOSE - MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,521.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,158.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,225.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,492.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$79,377.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$42,227.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,617.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$60,660.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,790.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,905.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,707.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,187.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,524.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,294.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,937.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,804.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,934.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,600.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,889.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,630.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,377.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,691.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-187,PLEURAL EFFUSION WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,515.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,649.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,596.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,982.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,129.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,118.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,971.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,808.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,640.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,777.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,089.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,876.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-199,PNEUMOTHORAX WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,601.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-200,PNEUMOTHORAX WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,200.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,352.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,449.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,288.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,680.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,916.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,147.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$91,622.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,676.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$178,526.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$166,881.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$103,884.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$82,291.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$128,881.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$86,398.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$72,836.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$134,737.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$99,393.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$117,795.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$90,028.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$105,788.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$84,030.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$99,444.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$63,808.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$135,843.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$94,372.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$124,683.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$85,078.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$96,483.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$65,292.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$76,939.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$44,638.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,462.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$59,560.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,521.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,051.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-245,AICD GENERATOR PROCEDURES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$86,624.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$50,011.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,811.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$50,782.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,068.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,364.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,556.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$53,131.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$42,459.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,952.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,688.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,289.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,576.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$51,220.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,923.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$57,347.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,860.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,329.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-263,VEIN LIGATION AND STRIPPING,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,884.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$51,964.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-265,AICD LEAD PROCEDURES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$53,803.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$113,555.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$89,614.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$111,273.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$69,033.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$82,905.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$57,033.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$43,020.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$61,395.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$52,566.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,019.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,913.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,608.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,833.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,747.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$7,942.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$35,425.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI - WITH CARDIAC CATHETERIZATION WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,400.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$42,896.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,281.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,377.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,454.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,321.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,441.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,513.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,700.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,516.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,273.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$7,811.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,502.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,675.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,880.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,496.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,822.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-304,HYPERTENSION WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,529.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-305,HYPERTENSION WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,816.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,059.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,894.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,188.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,990.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$8,934.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-311,ANGINA PECTORIS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,152.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-312,SYNCOPE AND COLLAPSE,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-313,CHEST PAIN,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,532.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,334.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,603.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,992.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$69,052.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$39,099.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$86,043.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$41,753.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,648.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$77,604.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,624.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,361.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-332,RECTAL RESECTION WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$66,555.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-333,RECTAL RESECTION WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$34,256.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,747.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$62,246.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,526.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,121.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$44,780.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,120.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,654.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$37,059.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,929.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,750.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$44,814.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,243.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,400.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$39,385.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,478.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,668.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$39,238.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,846.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,648.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$48,132.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,528.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,747.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$68,662.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,059.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,424.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,076.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,961.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,652.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,441.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,896.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,086.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,278.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,323.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,782.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,891.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,193.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,129.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,955.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,292.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,974.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,278.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,905.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,896.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,416.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,188.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,148.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$9,321.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,910.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,230.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,457.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,017.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,395.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$91,688.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-406,PANCREAS - LIVER AND SHUNT PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$46,032.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-407,PANCREAS - LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,856.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$59,992.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,828.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,051.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$60,038.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,411.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,702.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$58,008.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,510.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,755.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$38,776.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,009.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,043.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$56,225.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,542.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,222.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$66,864.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,505.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,692.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,113.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,456.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$9,913.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,044.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,923.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,312.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,540.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,510.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$9,694.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,139.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,905.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,604.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,700.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,059.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$147,097.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$97,569.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$76,656.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$137,569.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$104,032.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$80,278.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$107,708.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$62,923.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$97,219.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$50,307.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$85,846.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$47,592.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,497.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$85,520.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$57,219.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$44,864.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$49,350.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,398.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$80,268.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$48,851.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,643.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$65,164.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$35,097.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,556.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$53,710.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$37,710.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,948.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$48,392.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,528.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,348.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$38,180.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$54,521.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$34,374.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,244.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,593.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,771.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$55,491.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$37,203.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,630.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$58,147.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,769.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,339.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$41,348.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,179.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$50,462.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,920.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,292.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-503,FOOT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$42,059.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-504,FOOT PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,611.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,356.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,624.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-509,ARTHROSCOPY,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,780.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$43,691.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,496.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,899.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,944.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-514,HAND OR WRIST PROCEDURES - EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,907.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$50,192.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,377.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,347.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$57,348.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,323.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,678.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$49,014.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$35,025.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,601.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,617.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,740.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,345.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,931.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,542.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-539,OSTEOMYELITIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,059.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-540,OSTEOMYELITIS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,724.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,449.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,884.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,692.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,419.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$39,992.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,305.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,328.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,473.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-549,SEPTIC ARTHRITIS W CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,950.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,123.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,969.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,072.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,292.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,646.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,804.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,900.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-557,TENDONITIS - MYOSITIS AND BURSITIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,302.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,732.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,886.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,222.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,528.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,932.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,220.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,100.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,024.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$45,380.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,124.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,641.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$88,596.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$51,944.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,184.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$80,961.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,758.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,515.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$46,844.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,649.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,158.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,265.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,665.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,284.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,876.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-592,SKIN ULCERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,987.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-593,SKIN ULCERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,188.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,099.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,193.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,827.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,187.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,779.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,739.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,931.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,001.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-602,CELLULITIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,985.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-603,CELLULITIS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,516.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-604,TRAUMA TO THE SKIN - SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,860.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,547.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,176.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,209.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$38,188.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,185.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$63,820.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,545.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,848.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$48,977.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,177.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,542.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$57,804.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE - NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,966.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,508.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$45,459.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-626,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,436.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-627,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,908.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$59,169.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$37,548.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,510.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-637,DIABETES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,995.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-638,DIABETES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,070.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-639,DIABETES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$9,748.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,644.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,048.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,600.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,612.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,292.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,284.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$72,209.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$59,097.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-652,KIDNEY TRANSPLANT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$50,910.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$87,187.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$46,403.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,281.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$52,507.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,945.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,265.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$42,636.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,094.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,030.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$46,876.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,518.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,947.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-665,PROSTATECTOMY WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$48,587.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-666,PROSTATECTOMY WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,748.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,918.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$44,081.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,624.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,427.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,414.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$55,409.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$38,086.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,032.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-682,RENAL FAILURE WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,523.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-683,RENAL FAILURE WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,049.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$9,720.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,971.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,764.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,964.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,780.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,675.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-693,URINARY STONES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,300.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-694,URINARY STONES WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,668.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,180.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,035.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-697,URETHRAL STRICTURE,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,952.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,707.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,403.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,916.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,729.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,862.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,990.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,598.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$34,084.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,920.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,865.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,856.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,302.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,424.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,776.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,779.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,344.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,425.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,390.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,510.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,892.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,689.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,856.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,076.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$9,051.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-734,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$35,564.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-735,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,616.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$68,131.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,931.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,625.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$61,147.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,800.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,472.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,472.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,116.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,704.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,728.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-746,VAGINA - CERVIX AND VULVA PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,750.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,008.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,572.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$43,318.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,454.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,136.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,041.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,657.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,353.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,472.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,931.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,761.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$9,440.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Vaginal Delivery,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,732.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,926.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,209.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,300.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-779,ABORTION WITHOUT D&C,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,646.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,C-Section,Per Diem,"$3,000.00 ",IP,"$1,275.00 ","$29,963.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,C-Section,Per Diem,"$3,000.00 ",IP,"$1,275.00 ","$17,518.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,C-Section,Per Diem,"$3,000.00 ",IP,"$1,275.00 ","$14,644.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,C-Section,Per Diem,"$3,000.00 ",IP,"$1,275.00 ","$25,457.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,C-Section,Per Diem,"$3,000.00 ",IP,"$1,275.00 ","$17,003.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,C-Section,Per Diem,"$3,000.00 ",IP,"$1,275.00 ","$14,193.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Neonate,Per Diem,$600.00 ,IP,$600.00 ,"$27,496.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Neonate,Per Diem,$600.00 ,IP,$600.00 ,"$90,673.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Neonate,Per Diem,$600.00 ,IP,$600.00 ,"$61,926.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Neonate,Per Diem,$600.00 ,IP,$600.00 ,"$37,364.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Neonate,Per Diem,$600.00 ,IP,$600.00 ,"$63,611.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Neonate,Per Diem,$600.00 ,IP,$600.00 ,"$22,515.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-795,NORMAL NEWBORN,Normal Newborn,Per Diem,"$2,100.00 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Vaginal Delivery,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,086.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Vaginal Delivery,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,718.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Vaginal Delivery,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,236.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-799,SPLENECTOMY WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$82,302.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-800,SPLENECTOMY WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$47,222.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,936.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$59,339.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,156.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,827.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Vaginal Delivery,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,428.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Vaginal Delivery,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,742.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Vaginal Delivery,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,257.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$34,846.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,547.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,371.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,041.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,075.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-813,COAGULATION DISORDERS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$24,715.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,251.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,880.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,574.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,828.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,064.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,966.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$90,996.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$34,481.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,025.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$71,953.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$37,803.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$22,411.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$80,588.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$39,961.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,843.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$51,291.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,624.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,937.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,476.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$8,576.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$96,801.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,819.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,713.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$91,185.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,140.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,780.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$51,451.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,932.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,524.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,446.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,888.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,558.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$42,718.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,363.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,464.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-849,RADIOTHERAPY,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$39,800.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$79,113.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$33,510.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,920.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$72,731.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,555.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,574.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,060.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,638.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,000.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-865,VIRAL ILLNESS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,662.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$35,672.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,934.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,616.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$102,796.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,891.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,345.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$52,180.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Psychiatric,Per Diem,$550.00 ,IP,$550.00 ,"$13,817.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-881,DEPRESSIVE NEUROSES,Psychiatric,Per Diem,$550.00 ,IP,$550.00 ,"$12,822.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Psychiatric,Per Diem,$550.00 ,IP,$550.00 ,"$13,168.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Psychiatric,Per Diem,$550.00 ,IP,$550.00 ,"$25,252.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Psychiatric,Per Diem,$550.00 ,IP,$550.00 ,"$23,100.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-885,PSYCHOSES,Psychiatric,Per Diem,$550.00 ,IP,$550.00 ,"$19,793.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Psychiatric,Per Diem,$550.00 ,IP,$550.00 ,"$19,544.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Psychiatric,Per Diem,$550.00 ,IP,$550.00 ,"$17,259.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$68,195.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,398.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$18,150.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$59,542.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,345.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$28,700.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$63,313.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$32,646.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,993.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,182.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$27,161.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$10,516.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,640.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$29,350.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$16,436.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,062.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$25,401.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,886.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$336,494.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$104,419.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$48,142.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$36,121.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$31,044.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-935,NON-EXTENSIVE BURNS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,932.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$54,179.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$35,481.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$30,795.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$19,041.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$12,569.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-949,AFTERCARE WITH CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,713.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$11,822.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$8,931.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$100,608.00 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$61,580.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$118,732.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$67,286.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$43,747.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$43,587.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$23,814.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$14,606.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$92,598.40 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$47,121.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$42,971.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$20,465.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$15,185.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Medical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$21,132.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$73,724.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$40,659.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,476.80 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$52,193.60 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$26,891.20 ",,,,,,,,,,,,
Humana Choice Care,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Surgical,Per Diem,"$1,750.00 ",IP,"$1,275.00 ","$17,854.40 ",,,,,,,,,,,,
Humana Choice Care,ExceptRevenue,120,Room & Board (Semi-Private 2 beds),Acute Rehab,Per Diem,$650.00 ,IP,$650.00 ,$650.00 ,,,,,,,,,,,,
Humana Choice Care,ExceptRevenue,121,Medical/Surgical/Gyn,Acute Rehab,Per Diem,$650.00 ,IP,$650.00 ,$650.00 ,,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$463,441.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$254,896.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$303,857.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$189,792.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$163,572.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$75,067.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-007,LUNG TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$185,188.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$86,828.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-010,PANCREAS TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,883.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,262.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$61,310.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-013,TRACHEOSTOMY FOR FACE - MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,528.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$204,460.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$107,619.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$77,283.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$597,264.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$106,590.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$165,121.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$120,505.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$77,753.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$90,596.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$62,920.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$71,867.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,928.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,188.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$93,120.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,720.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,713.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$69,857.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,395.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,531.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,593.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,393.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,619.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,395.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,516.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,224.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,324.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,617.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,158.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,521.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,177.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,852.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,694.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,996.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,227.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,787.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,024.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,649.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-061,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,211.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-062,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,795.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,358.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,608.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,291.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,374.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,793.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,577.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,822.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,172.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,339.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,190.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,294.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,016.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,694.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,184.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,628.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,472.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,352.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,129.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,467.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,467.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,902.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,366.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,801.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-088,CONCUSSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,348.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-089,CONCUSSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,979.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,676.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,382.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,777.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,500.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$58,129.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,128.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,304.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$60,041.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,774.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,356.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-100,SEIZURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,977.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-101,SEIZURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,192.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-102,HEADACHES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,427.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-103,HEADACHES W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,251.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,068.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,128.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,252.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,035.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,622.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,019.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,300.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,244.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,380.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,366.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,249.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,088.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,497.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,489.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-139,SALIVARY GLAND PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,628.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,689.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,320.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,740.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$47,420.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,008.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-145,OTHER EAR - NOSE - MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,416.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,529.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,817.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,580.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-149,DYSEQUILIBRIUM,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,768.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-150,EPISTAXIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,195.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-151,EPISTAXIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,792.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,230.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,369.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,680.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,508.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-156,OTHER EAR - NOSE - MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,521.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,158.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,225.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,492.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$79,377.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,227.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,617.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$60,660.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,790.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,905.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,707.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,187.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,524.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,294.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,937.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,804.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,934.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,600.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,889.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,630.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,377.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,691.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-187,PLEURAL EFFUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,515.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,649.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,596.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,982.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,129.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,118.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,971.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,808.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,640.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,777.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,089.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,876.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-199,PNEUMOTHORAX WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,601.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-200,PNEUMOTHORAX WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,200.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,352.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,449.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,288.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,680.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,916.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,147.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$91,622.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,676.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$178,526.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$166,881.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$103,884.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$82,291.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$128,881.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$86,398.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$72,836.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$134,737.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$99,393.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$117,795.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$90,028.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$105,788.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$84,030.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$99,444.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,808.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$135,843.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$94,372.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$124,683.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$85,078.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$96,483.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$65,292.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$76,939.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,638.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,462.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,560.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,521.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,051.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-245,AICD GENERATOR PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$86,624.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,011.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,811.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,782.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,068.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,364.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,556.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$53,131.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,459.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,952.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,688.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,289.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,576.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,220.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,923.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,347.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,860.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,329.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-263,VEIN LIGATION AND STRIPPING,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,884.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,964.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-265,AICD LEAD PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$53,803.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$113,555.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$89,614.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$111,273.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$69,033.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$82,905.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,033.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,020.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$61,395.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,566.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,019.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,913.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,608.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,833.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,747.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$7,942.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,425.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI - WITH CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,400.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,896.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,281.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,377.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,454.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,321.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,441.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,513.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,700.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,516.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,273.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$7,811.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,502.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,675.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,880.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,496.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,822.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-304,HYPERTENSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,529.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-305,HYPERTENSION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,816.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,059.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,894.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,188.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,990.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$8,934.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-311,ANGINA PECTORIS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,152.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-312,SYNCOPE AND COLLAPSE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-313,CHEST PAIN,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,532.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,334.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,603.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,992.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$69,052.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,099.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$86,043.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$41,753.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,648.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$77,604.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,624.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,361.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-332,RECTAL RESECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$66,555.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-333,RECTAL RESECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,256.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,747.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$62,246.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,526.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,121.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,780.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,120.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,654.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,059.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,929.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,750.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,814.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,243.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,400.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,385.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,478.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,668.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,238.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,846.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,648.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,132.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,528.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,747.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$68,662.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,059.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,424.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,076.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,961.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,652.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,441.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,896.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,086.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,278.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,323.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,782.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,891.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,193.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,129.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,955.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,292.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,974.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,278.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,905.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,896.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,416.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,188.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,148.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,321.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,910.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,230.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,457.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,017.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,395.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$91,688.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-406,PANCREAS - LIVER AND SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,032.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-407,PANCREAS - LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,856.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,992.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,828.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,051.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$60,038.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,411.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,702.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$58,008.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,510.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,755.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$38,776.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,009.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,043.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$56,225.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,542.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,222.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$66,864.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,505.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,692.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,113.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,456.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,913.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,044.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,923.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,312.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,540.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,510.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,694.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,139.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,905.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,604.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,700.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,228.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,059.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$147,097.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$97,569.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$76,656.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$137,569.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$104,032.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,278.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$107,708.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$62,923.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$97,219.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,307.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$85,846.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$47,592.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,497.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$85,520.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,219.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,864.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$49,350.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,398.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,268.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,851.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,643.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$65,164.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,097.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,556.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$53,710.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,710.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,948.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,392.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,528.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,348.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$38,180.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$54,521.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,374.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,244.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,593.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,771.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$55,491.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,203.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,630.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$58,147.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,769.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,339.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$41,348.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,179.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,462.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,920.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,292.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-503,FOOT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,059.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-504,FOOT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,382.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,611.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,356.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,624.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-509,ARTHROSCOPY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,780.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,691.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,496.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,899.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,944.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-514,HAND OR WRIST PROCEDURES - EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,907.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,192.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,377.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,347.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,348.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,323.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,678.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$49,014.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,025.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,601.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,617.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,740.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,345.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,931.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,542.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-539,OSTEOMYELITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,059.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-540,OSTEOMYELITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,724.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,449.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,884.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,692.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,419.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,992.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,305.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,328.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,473.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-549,SEPTIC ARTHRITIS W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,950.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,123.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,969.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,072.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,292.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,646.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,804.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,900.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-557,TENDONITIS - MYOSITIS AND BURSITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,302.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,732.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,886.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,222.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,528.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,932.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,220.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,100.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,024.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$45,380.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,124.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,641.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$88,596.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,944.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,184.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,961.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,758.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,515.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,844.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,649.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,158.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,265.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,665.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,284.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,876.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-592,SKIN ULCERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,987.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-593,SKIN ULCERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,188.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,099.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,193.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,827.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,187.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,779.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,739.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,931.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,001.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-602,CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,985.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-603,CELLULITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,516.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-604,TRAUMA TO THE SKIN - SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,860.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,547.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,176.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,209.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$38,188.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,185.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,820.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,545.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,848.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,977.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,177.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,542.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$57,804.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE - NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,966.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,508.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$45,459.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-626,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,436.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-627,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,908.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,169.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,548.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,510.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-637,DIABETES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,995.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-638,DIABETES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,070.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-639,DIABETES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,748.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,644.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,048.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,600.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,612.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,292.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,284.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$72,209.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,097.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-652,KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$50,910.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$87,187.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,403.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,281.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,507.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,945.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,265.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,636.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,094.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,030.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$46,876.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,518.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,947.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-665,PROSTATECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,587.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-666,PROSTATECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,748.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,918.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$44,081.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,510.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,624.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,427.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,414.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$55,409.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$38,086.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,032.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-682,RENAL FAILURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,523.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-683,RENAL FAILURE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,049.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,720.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,971.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,764.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,964.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,780.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,675.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-693,URINARY STONES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,300.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-694,URINARY STONES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,668.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,180.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,035.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-697,URETHRAL STRICTURE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,952.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,707.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,403.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,916.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,729.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,862.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,990.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,598.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,084.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,920.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,865.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,856.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,302.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,424.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,776.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,779.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,344.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,425.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,390.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,510.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,892.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,689.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,856.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,076.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,051.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-734,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,564.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-735,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,616.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$68,131.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,931.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,625.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$61,147.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,800.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,472.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,472.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,116.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,704.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,728.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-746,VAGINA - CERVIX AND VULVA PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,750.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,008.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,572.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,318.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,454.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,136.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,041.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,657.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,353.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,472.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,931.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,761.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$9,440.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,732.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,926.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,209.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,300.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-779,ABORTION WITHOUT D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,646.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,963.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,518.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,644.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,457.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,003.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,193.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$27,496.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$90,673.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$61,926.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$37,364.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$63,611.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,$600.00 ,"$22,515.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-795,NORMAL NEWBORN,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,086.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,718.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,236.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-799,SPLENECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$82,302.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-800,SPLENECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$47,222.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,936.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,339.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,156.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,827.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,428.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,742.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,257.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,846.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,547.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,371.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,041.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,075.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-813,COAGULATION DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$24,715.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,251.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,880.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,574.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,828.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,064.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,966.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$90,996.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$34,481.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,025.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$71,953.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$37,803.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$22,411.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$80,588.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,961.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,843.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,291.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,624.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,937.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,476.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$8,576.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$96,801.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,819.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,713.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$91,185.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,140.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,780.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$51,451.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,932.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,524.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,446.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,888.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,558.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,718.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,363.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,464.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-849,RADIOTHERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$39,800.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$79,113.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$33,510.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,920.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$72,731.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,555.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,574.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,060.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,638.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,000.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-865,VIRAL ILLNESS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,662.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,395.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,672.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,934.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,616.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$102,796.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,891.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,345.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,180.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$13,817.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-881,DEPRESSIVE NEUROSES,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$12,822.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$13,168.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$25,252.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$23,100.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-885,PSYCHOSES,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$19,793.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$19,544.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Acute Care,Per Diem,"$5,358.42 ",IP,$550.00 ,"$17,259.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$8,760.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,472.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-896,ALCOHOL - DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,432.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$13,208.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$68,195.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,398.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,150.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$59,542.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,345.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$28,700.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$63,313.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$32,646.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,993.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,182.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,217.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$27,161.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$10,516.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,640.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,657.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$29,350.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$16,436.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,062.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$25,401.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,886.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$336,494.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$104,419.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$48,142.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$36,121.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$31,044.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-935,NON-EXTENSIVE BURNS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,932.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$54,179.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$35,481.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$30,795.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-945,REHABILITATION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,755.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$18,035.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$19,041.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$12,569.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-949,AFTERCARE WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,713.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$11,822.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$8,931.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$100,608.00 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$61,580.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$118,732.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$67,286.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,747.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$43,587.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$23,814.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$14,606.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$92,598.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$47,121.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$42,971.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$20,465.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$15,185.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$21,132.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$73,724.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$40,659.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,476.80 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$52,193.60 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$26,891.20 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$17,854.40 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Humana Medicare Advantage,DRG,MS-999,UNGROUPABLE,Acute Care,Per Diem,"$5,358.42 ",IP,"$1,275.00 ","$5,358.42 ",,,,,,,,,,,,
Humana Medicare Advantage,ExceptPatType,14,,Swing Bed,Per Diem,"$4,816.25 ",IP,$640.00 ,"$4,816.25 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,$3.00 ,$3.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,$11.06 ,$11.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,$94.41 ,$94.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,$13.73 ,$13.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,$8.46 ,$8.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,$7.01 ,$7.01 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,$10.56 ,$10.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,$47.81 ,$47.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,$13.39 ,$13.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,$8.68 ,$8.68 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,$47.63 ,$47.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,$8.17 ,$8.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,$74.86 ,$74.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,$15.08 ,$15.08 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,$14.57 ,$14.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,$18.05 ,$18.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,$20.15 ,$20.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,$13.28 ,$13.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,$13.28 ,$13.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,$13.54 ,$13.54 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,$13.54 ,$13.54 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,$16.34 ,$16.34 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,$13.73 ,$13.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,$16.38 ,$16.38 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,$21.67 ,$21.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,$15.78 ,$15.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,$6.61 ,$6.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,$18.05 ,$18.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,$15.30 ,$15.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,$13.76 ,$13.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,$16.59 ,$16.59 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,$60.00 ,$60.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,$16.75 ,$16.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,$14.60 ,$14.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,$13.73 ,$13.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,$13.73 ,$13.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,$14.14 ,$14.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,$16.13 ,$16.13 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,$11.92 ,$11.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,$13.54 ,$13.54 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,$38.57 ,$38.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,$18.64 ,$18.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,$12.60 ,$12.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,$17.14 ,$17.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,$62.14 ,$62.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,$32.62 ,$32.62 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,$86.96 ,$86.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,$78.26 ,$78.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,$125.50 ,$125.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,$80.37 ,$80.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,$801.62 ,$801.62 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,$51.64 ,$51.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,$55.89 ,$55.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,$209.32 ,$209.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,$43.99 ,$43.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,$579.48 ,$579.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,$161.88 ,$161.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,$46.07 ,$46.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,$50.50 ,$50.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,$148.41 ,$148.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,$66.70 ,$66.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,$129.33 ,$129.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,$165.61 ,$165.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,$285.03 ,$285.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,$103.00 ,$103.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,$91.16 ,$91.16 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,$50.41 ,$50.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,$67.21 ,$67.21 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,$4.02 ,$4.02 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,$3.17 ,$3.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,$3.48 ,$3.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,$2.25 ,$2.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,$2.17 ,$2.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,$29.98 ,$29.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,$3.05 ,$3.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,$4.70 ,$4.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,$8.61 ,$8.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,$3.64 ,$3.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,$295.79 ,$295.79 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,$279.00 ,$279.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"$1,824.88 ","$1,824.88 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,$468.00 ,$468.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,$584.23 ,$584.23 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,$300.00 ,$300.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,$676.50 ,$676.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,$241.90 ,$241.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,$846.27 ,$846.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,$518.28 ,$518.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,$47.25 ,$47.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,$780.00 ,$780.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,$280.00 ,$280.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,$200.00 ,$200.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,$94.99 ,$94.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,$163.96 ,$163.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,$144.84 ,$144.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,$214.62 ,$214.62 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,$39.31 ,$39.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,$440.00 ,$440.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,$185.12 ,$185.12 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,$241.90 ,$241.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,$121.63 ,$121.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,$556.60 ,$556.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,$97.22 ,$97.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,$435.07 ,$435.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,$499.00 ,$499.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,$168.75 ,$168.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,$291.36 ,$291.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,$900.00 ,$900.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"$1,160.00 ","$1,160.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,$324.58 ,$324.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,$65.69 ,$65.69 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,$73.37 ,$73.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,$36.62 ,$36.62 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,$57.04 ,$57.04 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,$44.89 ,$44.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,$165.51 ,$165.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,$83.00 ,$83.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,$58.49 ,$58.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,$47.25 ,$47.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,$101.12 ,$101.12 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,$61.52 ,$61.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,$35.00 ,$35.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,$51.45 ,$51.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,$65.36 ,$65.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,$102.26 ,$102.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,$39.31 ,$39.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,$197.99 ,$197.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,$68.55 ,$68.55 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,$294.52 ,$294.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,$172.73 ,$172.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,$233.07 ,$233.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,$304.81 ,$304.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,$207.46 ,$207.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,$260.79 ,$260.79 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,$202.40 ,$202.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,$91.66 ,$91.66 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,$329.51 ,$329.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,$124.87 ,$124.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"$1,160.00 ","$1,160.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,$73.37 ,$73.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,$124.64 ,$124.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,$192.32 ,$192.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,$39.31 ,$39.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,$65.34 ,$65.34 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,$675.40 ,$675.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,$331.00 ,$331.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,$202.40 ,$202.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,$381.70 ,$381.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,$337.73 ,$337.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,$213.30 ,$213.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,$641.85 ,$641.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,$308.00 ,$308.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,$238.00 ,$238.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,$348.56 ,$348.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,$527.87 ,$527.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,$120.00 ,$120.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,$150.00 ,$150.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,$291.36 ,$291.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,$676.50 ,$676.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,$246.52 ,$246.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,$295.79 ,$295.79 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,$255.05 ,$255.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,$329.51 ,$329.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,$207.31 ,$207.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,$676.50 ,$676.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,$331.00 ,$331.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,$203.50 ,$203.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,$291.36 ,$291.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,$46.60 ,$46.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,$300.00 ,$300.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,$758.36 ,$758.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,$769.58 ,$769.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,$46.60 ,$46.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,$192.00 ,$192.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,$47.00 ,$47.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,$51.07 ,$51.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,$43.65 ,$43.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,$329.51 ,$329.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,$150.33 ,$150.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,$208.92 ,$208.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,$49.59 ,$49.59 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,$201.50 ,$201.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,$175.40 ,$175.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,$234.00 ,$234.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,$641.85 ,$641.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,$329.51 ,$329.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,$308.00 ,$308.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,$88.20 ,$88.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,$193.25 ,$193.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,$202.40 ,$202.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,$324.58 ,$324.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,$402.12 ,$402.12 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,$404.52 ,$404.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,$403.59 ,$403.59 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,$127.43 ,$127.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,$74.33 ,$74.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,$220.74 ,$220.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,$122.22 ,$122.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,$94.74 ,$94.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,$345.57 ,$345.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,$335.38 ,$335.38 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,$177.25 ,$177.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,$169.90 ,$169.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,$123.68 ,$123.68 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,$109.13 ,$109.13 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,$63.96 ,$63.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,$137.00 ,$137.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,$150.33 ,$150.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,$846.27 ,$846.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"$2,000.00 ","$2,000.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,$504.00 ,$504.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"$1,350.19 ","$1,350.19 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"$2,448.56 ","$2,448.56 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"$4,780.00 ","$4,780.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"$12,000.00 ","$12,000.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,$320.00 ,$320.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"$2,448.56 ","$2,448.56 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,$759.05 ,$759.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,$759.05 ,$759.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"$5,031.20 ","$5,031.20 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"$2,709.95 ","$2,709.95 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"$2,337.65 ","$2,337.65 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"$1,625.00 ","$1,625.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,$679.57 ,$679.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,$679.05 ,$679.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,$438.93 ,$438.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,$597.91 ,$597.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,$438.93 ,$438.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,$438.93 ,$438.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"$3,324.00 ","$3,324.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"$2,143.60 ","$2,143.60 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"$2,448.56 ","$2,448.56 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,$597.91 ,$597.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,$759.53 ,$759.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"$2,919.60 ","$2,919.60 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"$1,287.00 ","$1,287.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,$936.00 ,$936.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,$914.00 ,$914.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,$914.00 ,$914.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,$840.65 ,$840.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"$1,050.00 ","$1,050.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,$260.50 ,$260.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,$897.00 ,$897.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,$520.00 ,$520.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,$68.92 ,$68.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,$795.00 ,$795.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,$54.30 ,$54.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,"$1,487.37 ","$1,487.37 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,$55.54 ,$55.54 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,$153.50 ,$153.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,$69.52 ,$69.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,$142.63 ,$142.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,$262.99 ,$262.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"$2,510.21 ","$2,510.21 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"$3,116.00 ","$3,116.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,$508.87 ,$508.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"$7,193.00 ","$7,193.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,$579.46 ,$579.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,$177.56 ,$177.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"$2,871.00 ","$2,871.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"$3,750.00 ","$3,750.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"$3,600.00 ","$3,600.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"$2,030.00 ","$2,030.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"$7,776.00 ","$7,776.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"$5,500.00 ","$5,500.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"$3,240.00 ","$3,240.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,$72.19 ,$72.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,$4.52 ,$4.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,$8.17 ,$8.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,$12.29 ,$12.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,$16.49 ,$16.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,$38.62 ,$38.62 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,$25.80 ,$25.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,$7.78 ,$7.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,$5.78 ,$5.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,$6.23 ,$6.23 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,$33.94 ,$33.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,$30.00 ,$30.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,$17.27 ,$17.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,$9.71 ,$9.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,$40.75 ,$40.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,$13.44 ,$13.44 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,$14.46 ,$14.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,$16.77 ,$16.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,$17.00 ,$17.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,$64.41 ,$64.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,$25.48 ,$25.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,$5.99 ,$5.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,$14.18 ,$14.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,$13.87 ,$13.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,$22.98 ,$22.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,$16.45 ,$16.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,$19.61 ,$19.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,$14.57 ,$14.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,$9.35 ,$9.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,$6.48 ,$6.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,$28.83 ,$28.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,$29.28 ,$29.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,$25.55 ,$25.55 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,$20.52 ,$20.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,$14.60 ,$14.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,$21.09 ,$21.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,$18.97 ,$18.97 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,$9.89 ,$9.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,$15.90 ,$15.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,$16.18 ,$16.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,$17.12 ,$17.12 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,$26.58 ,$26.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,$5.02 ,$5.02 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,$5.02 ,$5.02 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,$4.56 ,$4.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,$4.38 ,$4.38 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,$5.32 ,$5.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,$4.23 ,$4.23 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,$15.92 ,$15.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,$5.16 ,$5.16 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,$23.64 ,$23.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,$29.60 ,$29.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,$26.79 ,$26.79 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,$5.16 ,$5.16 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,$13.68 ,$13.68 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,$13.34 ,$13.34 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,$6.03 ,$6.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,$11.58 ,$11.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,$12.90 ,$12.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,$12.52 ,$12.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,$18.06 ,$18.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,$4.88 ,$4.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,$12.32 ,$12.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,$14.07 ,$14.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,$18.96 ,$18.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,$9.22 ,$9.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,$27.30 ,$27.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,$29.08 ,$29.08 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,$25.25 ,$25.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,$18.06 ,$18.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,$14.12 ,$14.12 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,$12.67 ,$12.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,$4.60 ,$4.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,$5.00 ,$5.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,$6.01 ,$6.01 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,$4.35 ,$4.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,$7.87 ,$7.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,$9.81 ,$9.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,$20.65 ,$20.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,$20.28 ,$20.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,$27.80 ,$27.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,$18.68 ,$18.68 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,$12.41 ,$12.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,$22.52 ,$22.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,$16.71 ,$16.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,$16.30 ,$16.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,$4.64 ,$4.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,$24.09 ,$24.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,$6.51 ,$6.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,$13.39 ,$13.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,$11.55 ,$11.55 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,$11.87 ,$11.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,$5.12 ,$5.12 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,$9.46 ,$9.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,$14.14 ,$14.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,$19.40 ,$19.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,$15.08 ,$15.08 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,$14.32 ,$14.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,$18.52 ,$18.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,$9.55 ,$9.55 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,$25.27 ,$25.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,$22.23 ,$22.23 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,$30.98 ,$30.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,$29.28 ,$29.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,$12.25 ,$12.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,$29.28 ,$29.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,$38.50 ,$38.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,$22.17 ,$22.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,$44.03 ,$44.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,$61.50 ,$61.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,$18.79 ,$18.79 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,$27.94 ,$27.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,$32.30 ,$32.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,$21.70 ,$21.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,$24.18 ,$24.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,$24.95 ,$24.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,$27.94 ,$27.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,$14.90 ,$14.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,$26.24 ,$26.24 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,$5.10 ,$5.10 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,$16.80 ,$16.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,$22.97 ,$22.97 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,$18.77 ,$18.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,$19.75 ,$19.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,$13.63 ,$13.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,$64.41 ,$64.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,$18.54 ,$18.54 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,$14.70 ,$14.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,$17.65 ,$17.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,$17.34 ,$17.34 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,$21.48 ,$21.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,$11.20 ,$11.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,$21.07 ,$21.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,$11.74 ,$11.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,$44.25 ,$44.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,$9.30 ,$9.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,$16.46 ,$16.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,$8.02 ,$8.02 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,$11.00 ,$11.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,$26.07 ,$26.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,$78.77 ,$78.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,$9.77 ,$9.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,$13.34 ,$13.34 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,$6.71 ,$6.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,$17.69 ,$17.69 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,$17.63 ,$17.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,$14.29 ,$14.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,$3.93 ,$3.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,$17.77 ,$17.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,$3.93 ,$3.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,$5.04 ,$5.04 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,$4.75 ,$4.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,$3.92 ,$3.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,$9.70 ,$9.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,$6.05 ,$6.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,$3.28 ,$3.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,$21.48 ,$21.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,$13.15 ,$13.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,$7.20 ,$7.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,$15.45 ,$15.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,$16.76 ,$16.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,$18.58 ,$18.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,$18.52 ,$18.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,$16.67 ,$16.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,$75.60 ,$75.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,$67.36 ,$67.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,$12.58 ,$12.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,$26.89 ,$26.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,$67.36 ,$67.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,$7.86 ,$7.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,$20.94 ,$20.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,$21.96 ,$21.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,$18.06 ,$18.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,$4.01 ,$4.01 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,$8.00 ,$8.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,$9.71 ,$9.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,$9.71 ,$9.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,$6.49 ,$6.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,$8.20 ,$8.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,$7.31 ,$7.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,$8.80 ,$8.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,$9.00 ,$9.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,$9.47 ,$9.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,$3.95 ,$3.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,$4.75 ,$4.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,$16.87 ,$16.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,$29.53 ,$29.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,$17.92 ,$17.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,$22.41 ,$22.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,$12.90 ,$12.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,$27.17 ,$27.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,$22.65 ,$22.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,$24.30 ,$24.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,$9.64 ,$9.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,$18.40 ,$18.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,$17.27 ,$17.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,$11.43 ,$11.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,$12.95 ,$12.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,$19.82 ,$19.82 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,$8.74 ,$8.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,$8.85 ,$8.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,$15.47 ,$15.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,$12.80 ,$12.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,$28.50 ,$28.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,$11.57 ,$11.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,$6.04 ,$6.04 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,$12.79 ,$12.79 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,$19.70 ,$19.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,$19.63 ,$19.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,$20.22 ,$20.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,$11.25 ,$11.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,$12.11 ,$12.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,$21.99 ,$21.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,$18.91 ,$18.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,$18.91 ,$18.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,$19.32 ,$19.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,$9.81 ,$9.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,$6.89 ,$6.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,$14.32 ,$14.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,$46.31 ,$46.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,$11.26 ,$11.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,$33.86 ,$33.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,$34.19 ,$34.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,$8.19 ,$8.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,$12.75 ,$12.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,$10.50 ,$10.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,$34.19 ,$34.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,$17.19 ,$17.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,$6.70 ,$6.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,$7.37 ,$7.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,$26.65 ,$26.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,$16.26 ,$16.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,$16.94 ,$16.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,$22.48 ,$22.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,$28.50 ,$28.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,$17.20 ,$17.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,$12.92 ,$12.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,$50.86 ,$50.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,$39.26 ,$39.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,$13.60 ,$13.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,$24.51 ,$24.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,$11.15 ,$11.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,$27.39 ,$27.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,$23.60 ,$23.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,$16.45 ,$16.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,$21.21 ,$21.21 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,$6.61 ,$6.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,$6.82 ,$6.82 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,$29.85 ,$29.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,$14.45 ,$14.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,$64.41 ,$64.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,$64.41 ,$64.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,$41.28 ,$41.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,$3.58 ,$3.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,$3.58 ,$3.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,$19.63 ,$19.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,$5.50 ,$5.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,$3.98 ,$3.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,$7.64 ,$7.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,$9.66 ,$9.66 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,$8.26 ,$8.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,$14.78 ,$14.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,$16.52 ,$16.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,$10.73 ,$10.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,$4.74 ,$4.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,$5.78 ,$5.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,$5.82 ,$5.82 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,$8.44 ,$8.44 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,$98.11 ,$98.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,$13.36 ,$13.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,$14.71 ,$14.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,$39.11 ,$39.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,$4.76 ,$4.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,$4.73 ,$4.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,$14.59 ,$14.59 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,$21.27 ,$21.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,$21.05 ,$21.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,$20.67 ,$20.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,$22.81 ,$22.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,$20.86 ,$20.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,$27.22 ,$27.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,$19.38 ,$19.38 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,$41.77 ,$41.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,$18.39 ,$18.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,$18.39 ,$18.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,$18.39 ,$18.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,$3.67 ,$3.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,$3.67 ,$3.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,$4.00 ,$4.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,$5.61 ,$5.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,$15.05 ,$15.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,$17.83 ,$17.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,$17.03 ,$17.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,$29.21 ,$29.21 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,$14.35 ,$14.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,$9.74 ,$9.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,$26.69 ,$26.69 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,$28.10 ,$28.10 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,$14.48 ,$14.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,$11.63 ,$11.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,$87.88 ,$87.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,$64.88 ,$64.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,$71.23 ,$71.23 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,$36.57 ,$36.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,$21.99 ,$21.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,$20.24 ,$20.24 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,$25.53 ,$25.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,$30.98 ,$30.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,$21.73 ,$21.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,$13.44 ,$13.44 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,$25.21 ,$25.21 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,$4.81 ,$4.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,$5.06 ,$5.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,$4.86 ,$4.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,$21.26 ,$21.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,$18.28 ,$18.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,$8.10 ,$8.10 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,$3.28 ,$3.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,$39.00 ,$39.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,$5.50 ,$5.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,$5.50 ,$5.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,$5.49 ,$5.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,$25.47 ,$25.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,$25.81 ,$25.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,$51.28 ,$51.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,$21.23 ,$21.23 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,$11.63 ,$11.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,$35.11 ,$35.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,$16.06 ,$16.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,$6.87 ,$6.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,$9.02 ,$9.02 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,$14.78 ,$14.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,$16.80 ,$16.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,$50.86 ,$50.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,$14.18 ,$14.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,$18.00 ,$18.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,$5.30 ,$5.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,$12.76 ,$12.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,$5.74 ,$5.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,$14.18 ,$14.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,$16.94 ,$16.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,$15.76 ,$15.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,$12.47 ,$12.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,$7.20 ,$7.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,$7.30 ,$7.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,$9.93 ,$9.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,$10.63 ,$10.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,$10.09 ,$10.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,$3.95 ,$3.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,$5.13 ,$5.13 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,$5.56 ,$5.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,$7.20 ,$7.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,$4.52 ,$4.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,$5.08 ,$5.08 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,$16.80 ,$16.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,$4.47 ,$4.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,$9.55 ,$9.55 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,$6.05 ,$6.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,$15.50 ,$15.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,$35.33 ,$35.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,$33.94 ,$33.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,$11.61 ,$11.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,$17.06 ,$17.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,$13.72 ,$13.72 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,$17.11 ,$17.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,$12.91 ,$12.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,$11.39 ,$11.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,$15.05 ,$15.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,$7.52 ,$7.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,$15.29 ,$15.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,$12.70 ,$12.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,$4.82 ,$4.82 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,$3.80 ,$3.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,$3.43 ,$3.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,$5.07 ,$5.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,$7.00 ,$7.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,$2.37 ,$2.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,$2.37 ,$2.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,$7.77 ,$7.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,$4.31 ,$4.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,$3.02 ,$3.02 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,$4.31 ,$4.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,$5.57 ,$5.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,$2.54 ,$2.54 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,$4.48 ,$4.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,$35.74 ,$35.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,$11.89 ,$11.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,$16.30 ,$16.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,$20.37 ,$20.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,$12.98 ,$12.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,$17.65 ,$17.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,$20.42 ,$20.42 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,$22.94 ,$22.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,$22.94 ,$22.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,$22.94 ,$22.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,$19.04 ,$19.04 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,$17.90 ,$17.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,$19.35 ,$19.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,$16.34 ,$16.34 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,$9.11 ,$9.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,$18.93 ,$18.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,$18.93 ,$18.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,$11.85 ,$11.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,$10.81 ,$10.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,$12.01 ,$12.01 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,$13.84 ,$13.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,$11.61 ,$11.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,$15.32 ,$15.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,$15.32 ,$15.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,$17.27 ,$17.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,$4.69 ,$4.69 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,$4.28 ,$4.28 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,$4.49 ,$4.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,$8.41 ,$8.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,$6.89 ,$6.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,$80.46 ,$80.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,$12.43 ,$12.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,$9.72 ,$9.72 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,$9.72 ,$9.72 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,$14.46 ,$14.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,$15.48 ,$15.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,$30.86 ,$30.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,$7.71 ,$7.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,$7.71 ,$7.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,$17.19 ,$17.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,$6.53 ,$6.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,$4.20 ,$4.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,$6.82 ,$6.82 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,$7.73 ,$7.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,$9.36 ,$9.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,$8.87 ,$8.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,$13.09 ,$13.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,$11.84 ,$11.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,$13.09 ,$13.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,$6.88 ,$6.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,$8.60 ,$8.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,$8.60 ,$8.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,$18.75 ,$18.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,$7.47 ,$7.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,$13.36 ,$13.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,$24.91 ,$24.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,$17.98 ,$17.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,$17.98 ,$17.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,$4.29 ,$4.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,$3.94 ,$3.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,$17.49 ,$17.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,$9.58 ,$9.58 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,$9.85 ,$9.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,$2.70 ,$2.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,$5.51 ,$5.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,$5.77 ,$5.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,$6.85 ,$6.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,$9.63 ,$9.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,$6.01 ,$6.01 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,$11.67 ,$11.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,$6.98 ,$6.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,$7.82 ,$7.82 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,$5.22 ,$5.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,$7.97 ,$7.97 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,$17.93 ,$17.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,$15.05 ,$15.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,$18.37 ,$18.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,$12.46 ,$12.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,$12.09 ,$12.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,$11.16 ,$11.16 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,$7.30 ,$7.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,$5.77 ,$5.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,$12.95 ,$12.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,$25.45 ,$25.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,$25.45 ,$25.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,$16.07 ,$16.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,$15.99 ,$15.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,$8.07 ,$8.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,$8.06 ,$8.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,$12.00 ,$12.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,$12.00 ,$12.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,$20.32 ,$20.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,$10.01 ,$10.01 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,$12.95 ,$12.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,$13.74 ,$13.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,$12.11 ,$12.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,$17.93 ,$17.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,$12.05 ,$12.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,$12.05 ,$12.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,$8.19 ,$8.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,$25.57 ,$25.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,$7.37 ,$7.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,$20.81 ,$20.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,$14.99 ,$14.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,$18.09 ,$18.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,$29.92 ,$29.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,$23.13 ,$23.13 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,$29.92 ,$29.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,$14.05 ,$14.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,$24.37 ,$24.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,$22.34 ,$22.34 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,$29.35 ,$29.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,$15.59 ,$15.59 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,$21.41 ,$21.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,$15.08 ,$15.08 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,$23.57 ,$23.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,$12.46 ,$12.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,$10.39 ,$10.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,$135.86 ,$135.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,$49.03 ,$49.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,$37.73 ,$37.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,$26.78 ,$26.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,$37.73 ,$37.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,$37.73 ,$37.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,$46.98 ,$46.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,$26.78 ,$26.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,$77.78 ,$77.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,$14.55 ,$14.55 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,$16.91 ,$16.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,$13.61 ,$13.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,$21.78 ,$21.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,$11.54 ,$11.54 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,$10.64 ,$10.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,$6.14 ,$6.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,$5.67 ,$5.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,$61.98 ,$61.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,$100.00 ,$100.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,$12.66 ,$12.66 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,$4.40 ,$4.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,$15.05 ,$15.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,$12.88 ,$12.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,$12.90 ,$12.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,$15.49 ,$15.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,$17.03 ,$17.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,$13.38 ,$13.38 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,$8.93 ,$8.93 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,$13.12 ,$13.12 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,$12.01 ,$12.01 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,$11.82 ,$11.82 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,$12.68 ,$12.68 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,$11.47 ,$11.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,$12.12 ,$12.12 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,$14.41 ,$14.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,$16.85 ,$16.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,$15.21 ,$15.21 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,$13.03 ,$13.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,$13.12 ,$13.12 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,$15.29 ,$15.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,$18.14 ,$18.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,$10.18 ,$10.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,$14.16 ,$14.16 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,$12.25 ,$12.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,$14.72 ,$14.72 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,$16.85 ,$16.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,$13.01 ,$13.01 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,$15.84 ,$15.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,$9.09 ,$9.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,$14.00 ,$14.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,$19.35 ,$19.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,$17.16 ,$17.16 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,$19.35 ,$19.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,$13.79 ,$13.79 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,$8.89 ,$8.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,$13.52 ,$13.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,$13.71 ,$13.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,$12.05 ,$12.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,$11.77 ,$11.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,$11.57 ,$11.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,$12.39 ,$12.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,$11.26 ,$11.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,$13.55 ,$13.55 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,$16.89 ,$16.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,$15.30 ,$15.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,$12.25 ,$12.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,$16.20 ,$16.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,$12.87 ,$12.87 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,$15.00 ,$15.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,$13.05 ,$13.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,$13.24 ,$13.24 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,$15.99 ,$15.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,$15.03 ,$15.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,$12.39 ,$12.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,$15.89 ,$15.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,$19.35 ,$19.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,$18.23 ,$18.23 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,$12.88 ,$12.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,$24.48 ,$24.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,$14.80 ,$14.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,$14.41 ,$14.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,$13.24 ,$13.24 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,$12.56 ,$12.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,$12.88 ,$12.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,$16.85 ,$16.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,$14.39 ,$14.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,$12.88 ,$12.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,$13.19 ,$13.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,$16.85 ,$16.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,$15.91 ,$15.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,$14.27 ,$14.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,$15.49 ,$15.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,$189.51 ,$189.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,$47.59 ,$47.59 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,$78.65 ,$78.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,$29.68 ,$29.68 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,$25.81 ,$25.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,$58.00 ,$58.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,$30.17 ,$30.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,$106.14 ,$106.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,$36.56 ,$36.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,$109.49 ,$109.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,$36.53 ,$36.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,$64.19 ,$64.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,$64.19 ,$64.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,$95.52 ,$95.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,$81.88 ,$81.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,$323.75 ,$323.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,$325.80 ,$325.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,$357.56 ,$357.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,$322.96 ,$322.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,$8.77 ,$8.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,$12.11 ,$12.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,$16.84 ,$16.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,$6.68 ,$6.68 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,$10.32 ,$10.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,$9.44 ,$9.44 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,$8.62 ,$8.62 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,$9.89 ,$9.89 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,$9.66 ,$9.66 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,$9.47 ,$9.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,$8.08 ,$8.08 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,$8.08 ,$8.08 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,$6.63 ,$6.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,$27.07 ,$27.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,$8.07 ,$8.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,$8.09 ,$8.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,$7.71 ,$7.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,$8.41 ,$8.41 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,$20.46 ,$20.46 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,$10.32 ,$10.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,$10.32 ,$10.32 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,$15.39 ,$15.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,$19.60 ,$19.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,$10.80 ,$10.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,$14.61 ,$14.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,$5.57 ,$5.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,$12.52 ,$12.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,$5.18 ,$5.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,$7.74 ,$7.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,$115.36 ,$115.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,$7.74 ,$7.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,$10.74 ,$10.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,$11.30 ,$11.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,$4.31 ,$4.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,$5.88 ,$5.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,$8.90 ,$8.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,$4.75 ,$4.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,$7.48 ,$7.48 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,$4.75 ,$4.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,$40.17 ,$40.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,$6.64 ,$6.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,$7.31 ,$7.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,$15.02 ,$15.02 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,$5.39 ,$5.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,$5.99 ,$5.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,$17.98 ,$17.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,$5.82 ,$5.82 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,$19.74 ,$19.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,$19.56 ,$19.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,$26.07 ,$26.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,$20.20 ,$20.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,$19.56 ,$19.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,$33.86 ,$33.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,$14.43 ,$14.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,$13.61 ,$13.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,$12.25 ,$12.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,$16.07 ,$16.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,$15.60 ,$15.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,$16.43 ,$16.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,$60.80 ,$60.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,$12.18 ,$12.18 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,$16.10 ,$16.10 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,$15.00 ,$15.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,$13.42 ,$13.42 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,$13.82 ,$13.82 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,$12.66 ,$12.66 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,$14.38 ,$14.38 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,$10.33 ,$10.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,$10.33 ,$10.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,$11.53 ,$11.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,$13.25 ,$13.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,$24.08 ,$24.08 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,$24.06 ,$24.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,$21.90 ,$21.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,$14.13 ,$14.13 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,$13.91 ,$13.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,$16.81 ,$16.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,$10.51 ,$10.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,$55.74 ,$55.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,$416.78 ,$416.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,$22.75 ,$22.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,$53.47 ,$53.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,$37.27 ,$37.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,$30.03 ,$30.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,$51.31 ,$51.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,$95.80 ,$95.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,$29.22 ,$29.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,$128.29 ,$128.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,$262.99 ,$262.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,$416.78 ,$416.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,$31.22 ,$31.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,$29.80 ,$29.80 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,$39.26 ,$39.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,$58.00 ,$58.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,$21.92 ,$21.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,$85.10 ,$85.10 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,$21.92 ,$21.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,$58.62 ,$58.62 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,$48.24 ,$48.24 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,$26.88 ,$26.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,$41.68 ,$41.68 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,$27.29 ,$27.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,$302.62 ,$302.62 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,$26.88 ,$26.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,$40.55 ,$40.55 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,$142.63 ,$142.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,$218.06 ,$218.06 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,$416.78 ,$416.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,$70.20 ,$70.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,$41.76 ,$41.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,$20.05 ,$20.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,$51.31 ,$51.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,$30.03 ,$30.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,$42.84 ,$42.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,$43.67 ,$43.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,$70.20 ,$70.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,$12.73 ,$12.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,$16.55 ,$16.55 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,$32.77 ,$32.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,$13.10 ,$13.10 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,$15.29 ,$15.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,$21.76 ,$21.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,$35.29 ,$35.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,$24.56 ,$24.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,$16.53 ,$16.53 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,$16.07 ,$16.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,$130.35 ,$130.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,$257.45 ,$257.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,$257.45 ,$257.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,$488.66 ,$488.66 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,$26.07 ,$26.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,$12.22 ,$12.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,$128.73 ,$128.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,$257.45 ,$257.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,$257.45 ,$257.45 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,$17.98 ,$17.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,$7.99 ,$7.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,$20.26 ,$20.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,$23.04 ,$23.04 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,$50.56 ,$50.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,$27.64 ,$27.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,$24.03 ,$24.03 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,$14.65 ,$14.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,$42.22 ,$42.22 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,$25.37 ,$25.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,$26.61 ,$26.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,$116.49 ,$116.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,$140.73 ,$140.73 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,$150.30 ,$150.30 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,$143.75 ,$143.75 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,$147.52 ,$147.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,$13.07 ,$13.07 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,$12.09 ,$12.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,$173.17 ,$173.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,$173.17 ,$173.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,$173.17 ,$173.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,$264.34 ,$264.34 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,$125.49 ,$125.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,$150.29 ,$150.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,$144.61 ,$144.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,$188.57 ,$188.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,$173.66 ,$173.66 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,$21.42 ,$21.42 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,$40.70 ,$40.70 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,$34.81 ,$34.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,$42.38 ,$42.38 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,$51.19 ,$51.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,$33.47 ,$33.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,$68.60 ,$68.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,$26.91 ,$26.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,$34.43 ,$34.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,$5.02 ,$5.02 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,$5.02 ,$5.02 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,$9.37 ,$9.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,$9.37 ,$9.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,$4.72 ,$4.72 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,$5.60 ,$5.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,$7.33 ,$7.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,$5.88 ,$5.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,$4.85 ,$4.85 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,$5.79 ,$5.79 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,$9.84 ,$9.84 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,$8.61 ,$8.61 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,$12.31 ,$12.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,$12.05 ,$12.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,$15.50 ,$15.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,$10.67 ,$10.67 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,$19.59 ,$19.59 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,$10.38 ,$10.38 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,$19.59 ,$19.59 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,$720.00 ,$720.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,$503.40 ,$503.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,$25.00 ,$25.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,$503.40 ,$503.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,$950.00 ,$950.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,$79.00 ,$79.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,$150.00 ,$150.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,$375.00 ,$375.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,$597.91 ,$597.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,$107.00 ,$107.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,$427.26 ,$427.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"$2,515.60 ","$2,515.60 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"$2,515.60 ","$2,515.60 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,$176.19 ,$176.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"$2,515.60 ","$2,515.60 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,$163.96 ,$163.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,$91.66 ,$91.66 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"$3,002.09 ","$3,002.09 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"$3,675.00 ","$3,675.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"$1,950.00 ","$1,950.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,$248.51 ,$248.51 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,$34.19 ,$34.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,$85.77 ,$85.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"$3,600.00 ","$3,600.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,$121.91 ,$121.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,$742.27 ,$742.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,$134.13 ,$134.13 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,$174.81 ,$174.81 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,$349.62 ,$349.62 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,$466.17 ,$466.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,$540.99 ,$540.99 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"$4,780.00 ","$4,780.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"$3,500.00 ","$3,500.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,$29.60 ,$29.60 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,$13.74 ,$13.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,$409.90 ,$409.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,$17.21 ,$17.21 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,$17.21 ,$17.21 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,$14.86 ,$14.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,$14.86 ,$14.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,$407.43 ,$407.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"$3,873.00 ","$3,873.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"$2,919.60 ","$2,919.60 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,$407.43 ,$407.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"$2,916.60 ","$2,916.60 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,$193.71 ,$193.71 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,$33.86 ,$33.86 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"$2,030.00 ","$2,030.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,$148.96 ,$148.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"$3,240.00 ","$3,240.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"$2,515.60 ","$2,515.60 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,$322.96 ,$322.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,$322.96 ,$322.96 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,$759.05 ,$759.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,$25.10 ,$25.10 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,$380.72 ,$380.72 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,$750.00 ,$750.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,$31.33 ,$31.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,$18.09 ,$18.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,$15.29 ,$15.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"$1,897.00 ","$1,897.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,$142.63 ,$142.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,$380.00 ,$380.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,$676.37 ,$676.37 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,$600.00 ,$600.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,$43.43 ,$43.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,$450.91 ,$450.91 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"$3,520.00 ","$3,520.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,$246.92 ,$246.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,$167.35 ,$167.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,$720.00 ,$720.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,$200.00 ,$200.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"$3,159.42 ","$3,159.42 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"$3,159.42 ","$3,159.42 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"$1,755.00 ","$1,755.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"$2,488.00 ","$2,488.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,$62.14 ,$62.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"$7,582.20 ","$7,582.20 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,$771.98 ,$771.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,$363.04 ,$363.04 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,$950.00 ,$950.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,$874.49 ,$874.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,$16.00 ,$16.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"$2,513.25 ","$2,513.25 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,$142.63 ,$142.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,$27.11 ,$27.11 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,$682.29 ,$682.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,$356.13 ,$356.13 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"$1,938.01 ","$1,938.01 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,$275.35 ,$275.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,$246.92 ,$246.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,$840.65 ,$840.65 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"$2,753.25 ","$2,753.25 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,$83.76 ,$83.76 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"$2,510.21 ","$2,510.21 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,$509.20 ,$509.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,$526.23 ,$526.23 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,$357.63 ,$357.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,$584.90 ,$584.90 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,$710.00 ,$710.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,$741.64 ,$741.64 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,$690.29 ,$690.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,$748.39 ,$748.39 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,$700.56 ,$700.56 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,$407.43 ,$407.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,$468.33 ,$468.33 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,$482.14 ,$482.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,$503.40 ,$503.40 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,$7.52 ,$7.52 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,$466.17 ,$466.17 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"$1,755.00 ","$1,755.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"$3,030.00 ","$3,030.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,$64.19 ,$64.19 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,$301.35 ,$301.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,$375.25 ,$375.25 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,$282.88 ,$282.88 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,$274.83 ,$274.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,$185.20 ,$185.20 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,$416.78 ,$416.78 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,$760.00 ,$760.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"$2,919.60 ","$2,919.60 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,$47.00 ,$47.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,$18.63 ,$18.63 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"$2,279.00 ","$2,279.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"$3,500.00 ","$3,500.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"$5,000.00 ","$5,000.00 ",,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,$6.50 ,$6.50 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,$19.31 ,$19.31 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,$20.26 ,$20.26 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,$27.05 ,$27.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,$43.97 ,$43.97 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,$26.49 ,$26.49 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,$31.94 ,$31.94 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,$7.77 ,$7.77 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,$6.47 ,$6.47 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,$18.05 ,$18.05 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,$19.57 ,$19.57 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,$18.29 ,$18.29 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,$11.98 ,$11.98 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,$5.00 ,$5.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,$46.35 ,$46.35 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,$24.08 ,$24.08 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,$35.09 ,$35.09 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,$114.43 ,$114.43 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,$156.59 ,$156.59 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,$198.74 ,$198.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,$246.92 ,$246.92 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,$28.27 ,$28.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,$62.14 ,$62.14 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,$4.95 ,$4.95 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,$3.00 ,$3.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,$15.15 ,$15.15 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,$5.83 ,$5.83 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,$4.27 ,$4.27 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,$9.74 ,$9.74 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,$25.00 ,$25.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,$75.00 ,$75.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,$75.00 ,$75.00 ,,,,,,,,,,,,
Humana Medicare Advantage,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,$25.00 ,$25.00 ,,,,,,,,,,,,
Humana Medicare Advantage,,,,All Other,Straight Discount,30.00%,OP,,,,,,,,,,,,,,
Meridian Duals,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","463,441.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","254,896.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","303,857.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","189,792.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","163,572.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","75,067.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-007,LUNG TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","185,188.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,828.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-010,PANCREAS TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,883.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,262.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,310.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-013,TRACHEOSTOMY FOR FACE - MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,528.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","204,460.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","107,619.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,283.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","597,264.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","106,590.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","165,121.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","120,505.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,753.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,596.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,920.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","71,867.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,928.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,188.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","93,120.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,720.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,713.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,857.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,395.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,531.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,593.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,393.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,619.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,395.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,516.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,224.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,324.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,617.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,158.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,521.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,177.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,852.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,694.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,996.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,227.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,787.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,024.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,649.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-061,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,211.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-062,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,795.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,358.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,608.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,291.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,374.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,793.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,217.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,577.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,822.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,172.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,339.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,190.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,294.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,016.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,694.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,510.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,184.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,628.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,472.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,352.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,129.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,467.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,467.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,902.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,366.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,801.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-088,CONCUSSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,348.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-089,CONCUSSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,979.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,676.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,382.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,777.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,500.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,129.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,128.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,304.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,041.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,774.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,356.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-100,SEIZURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,977.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-101,SEIZURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,192.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-102,HEADACHES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,427.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-103,HEADACHES W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,251.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,068.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,128.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,252.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,035.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,622.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,019.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,300.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,244.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,380.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,366.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,249.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,088.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,497.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,489.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-139,SALIVARY GLAND PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,628.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,689.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,320.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,740.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,420.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,008.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-145,OTHER EAR - NOSE - MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,416.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,529.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,817.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,580.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-149,DYSEQUILIBRIUM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,768.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-150,EPISTAXIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,195.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-151,EPISTAXIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,792.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,230.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,369.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,680.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,508.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-156,OTHER EAR - NOSE - MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,521.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,158.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,225.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,492.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","79,377.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,227.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,617.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,660.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,790.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,905.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,707.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,187.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,524.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,294.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,937.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,804.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,934.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,600.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,889.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,630.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,377.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,691.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-187,PLEURAL EFFUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,515.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,649.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,596.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,982.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,129.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,118.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,971.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,808.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,640.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,777.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,089.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,876.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-199,PNEUMOTHORAX WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,601.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-200,PNEUMOTHORAX WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,200.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,352.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,449.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,288.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,680.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,916.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,147.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,622.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,676.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","178,526.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","166,881.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","103,884.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,291.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","128,881.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,398.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,836.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","134,737.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","99,393.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","117,795.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,028.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","105,788.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","84,030.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","99,444.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,808.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","135,843.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","94,372.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","124,683.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,078.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","96,483.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","65,292.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","76,939.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,638.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,462.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,560.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,521.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,051.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-245,AICD GENERATOR PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,624.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,011.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,811.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,782.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,068.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,364.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,556.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,131.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,459.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,952.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,688.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,289.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,576.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,220.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,923.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,347.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,860.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,329.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-263,VEIN LIGATION AND STRIPPING,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,884.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,964.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-265,AICD LEAD PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,803.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","113,555.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","89,614.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","111,273.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,033.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,905.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,033.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,020.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,395.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,566.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,019.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,913.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,608.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,833.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,747.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","7,942.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,425.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI - WITH CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,400.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,896.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,281.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,377.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,454.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,321.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,441.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,513.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,700.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,516.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,273.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","7,811.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,502.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,675.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,880.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,496.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,822.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-304,HYPERTENSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,529.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-305,HYPERTENSION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,816.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,059.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,894.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,188.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,990.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,934.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-311,ANGINA PECTORIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,152.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-312,SYNCOPE AND COLLAPSE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,395.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-313,CHEST PAIN,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,532.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,334.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,603.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,992.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,052.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,099.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,043.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","41,753.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,648.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,604.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,624.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,361.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-332,RECTAL RESECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","66,555.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-333,RECTAL RESECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,256.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,747.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,246.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,526.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,121.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,780.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,120.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,654.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,059.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,929.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,750.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,814.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,243.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,400.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,385.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,478.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,668.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,238.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,846.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,648.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,132.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,528.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,747.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,662.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,059.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,424.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,076.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,228.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,961.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,652.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,441.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,896.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,086.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,278.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,323.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,782.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,891.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,193.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,129.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,955.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,292.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,974.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,278.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,905.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,896.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,416.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,188.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,148.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,321.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,910.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,230.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,457.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,017.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,395.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,688.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-406,PANCREAS - LIVER AND SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,032.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-407,PANCREAS - LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,856.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,992.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,828.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,051.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,038.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,411.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,702.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,008.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,510.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,755.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,776.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,009.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,043.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","56,225.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,542.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,222.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","66,864.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,505.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,692.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,113.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,456.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,913.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,044.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,923.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,312.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,540.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,510.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,694.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,139.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,905.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,604.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,700.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,228.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,059.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","147,097.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","97,569.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","76,656.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","137,569.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","104,032.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,278.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","107,708.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,923.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","97,219.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,307.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,846.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,592.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,497.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,520.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,219.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,864.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","49,350.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,398.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,268.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,851.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,643.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","65,164.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,097.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,556.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,710.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,710.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,948.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,392.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,528.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,348.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,180.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","54,521.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,374.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,244.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,593.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,771.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","55,491.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,203.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,630.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,147.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,769.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,339.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","41,348.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,179.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,462.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,920.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,292.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-503,FOOT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,059.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-504,FOOT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,382.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,382.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,611.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,356.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,624.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-509,ARTHROSCOPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,780.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,691.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,496.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,899.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,944.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-514,HAND OR WRIST PROCEDURES - EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,907.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,192.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,377.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,347.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,348.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,323.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,678.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","49,014.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,025.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,601.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,617.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,740.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,345.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,931.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,542.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-539,OSTEOMYELITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,059.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-540,OSTEOMYELITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,724.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,449.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,884.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,692.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,419.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,992.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,305.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,328.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,473.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-549,SEPTIC ARTHRITIS W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,950.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,123.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,969.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,072.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,292.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,646.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,804.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,900.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-557,TENDONITIS - MYOSITIS AND BURSITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,302.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,732.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,886.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,222.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,657.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,528.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,932.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,220.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,100.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,024.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","45,380.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,124.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,641.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","88,596.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,944.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,184.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,961.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,758.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,515.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,844.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,649.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,158.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,265.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,665.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,284.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,876.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-592,SKIN ULCERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,987.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-593,SKIN ULCERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,188.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,099.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,193.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,827.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,187.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,779.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,739.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,931.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,001.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-602,CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,985.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-603,CELLULITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,516.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-604,TRAUMA TO THE SKIN - SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,860.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,547.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,176.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,209.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,188.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,185.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,820.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,545.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,848.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,977.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,177.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,542.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,804.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE - NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,966.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,508.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","45,459.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-626,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,436.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-627,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,908.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,169.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,548.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,510.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-637,DIABETES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,995.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-638,DIABETES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,070.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-639,DIABETES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,748.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,644.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,048.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,600.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,612.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,292.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,284.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,209.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,097.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-652,KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,910.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","87,187.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,403.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,281.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,507.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,945.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,265.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,636.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,094.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,030.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,876.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,518.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,947.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-665,PROSTATECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,587.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-666,PROSTATECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,748.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,918.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,081.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,510.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,624.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,427.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,414.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","55,409.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,086.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,032.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-682,RENAL FAILURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,523.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-683,RENAL FAILURE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,049.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,720.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,971.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,764.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,964.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,780.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,675.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-693,URINARY STONES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,300.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-694,URINARY STONES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,668.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,180.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,035.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-697,URETHRAL STRICTURE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,952.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,707.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,403.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,916.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,729.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,862.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,990.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,598.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,084.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,920.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,865.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,856.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,302.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,424.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,776.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,779.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,344.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,425.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,390.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,510.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,892.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,689.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,856.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,076.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,051.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-734,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,564.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-735,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,616.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,131.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,931.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,625.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,147.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,800.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,472.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,472.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,116.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,704.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,728.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-746,VAGINA - CERVIX AND VULVA PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,750.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,008.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,572.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,318.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,454.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,136.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,041.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,657.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,353.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,472.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,931.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,761.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,440.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,732.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,926.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,209.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,300.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-779,ABORTION WITHOUT D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,646.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,963.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,518.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,644.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,457.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,003.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,193.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Acute Care,Per Diem,"$5,358.42 ",IP,600,"27,496.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Acute Care,Per Diem,"$5,358.42 ",IP,600,"90,673.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"61,926.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"37,364.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"63,611.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"22,515.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-795,NORMAL NEWBORN,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
Meridian Duals,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,086.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,718.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,236.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-799,SPLENECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,302.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-800,SPLENECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,222.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,936.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,339.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,156.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,827.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,428.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,742.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,257.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,846.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,547.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,371.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,041.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,075.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-813,COAGULATION DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,715.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,251.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,880.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,574.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,828.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,064.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,966.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,996.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,481.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,025.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","71,953.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,803.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,411.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,588.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,961.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,843.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,291.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,624.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,937.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,476.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,576.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","96,801.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,819.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,713.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,185.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,140.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,780.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,451.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,932.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,524.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,446.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,888.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,558.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,718.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,363.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,464.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-849,RADIOTHERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,800.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","79,113.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,510.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,920.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,731.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,555.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,574.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,060.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,638.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,000.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-865,VIRAL ILLNESS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,662.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,395.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,672.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,934.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,616.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","102,796.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,891.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,345.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,180.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Acute Care,Per Diem,"$5,358.42 ",IP,550,"13,817.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-881,DEPRESSIVE NEUROSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"12,822.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Acute Care,Per Diem,"$5,358.42 ",IP,550,"13,168.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Acute Care,Per Diem,"$5,358.42 ",IP,550,"25,252.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Acute Care,Per Diem,"$5,358.42 ",IP,550,"23,100.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-885,PSYCHOSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"19,793.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,550,"19,544.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"17,259.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,760.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,472.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-896,ALCOHOL - DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,432.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,208.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,195.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,398.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,150.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,542.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,345.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,700.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,313.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,646.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,993.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,182.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,217.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,161.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,516.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,640.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,657.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,350.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,436.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,062.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,401.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,886.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","336,494.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","104,419.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,142.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,121.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,044.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-935,NON-EXTENSIVE BURNS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,932.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","54,179.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,481.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,795.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-945,REHABILITATION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,755.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,035.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,041.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,569.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-949,AFTERCARE WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,713.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,822.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,931.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","100,608.00",,,,,,,,,,,,
Meridian Duals,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,580.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","118,732.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","67,286.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,747.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,587.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,814.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,606.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","92,598.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,121.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,971.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,465.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,185.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,132.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","73,724.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,659.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,476.80",,,,,,,,,,,,
Meridian Duals,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,193.60",,,,,,,,,,,,
Meridian Duals,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,891.20",,,,,,,,,,,,
Meridian Duals,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,854.40",,,,,,,,,,,,
Meridian Duals,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
Meridian Duals,DRG,MS-999,UNGROUPABLE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
Meridian Duals,ExceptPatType,14,,Swing Bed,Per Diem,"$4,816.25 ",IP,640,"4,816.25",,,,,,,,,,,,
Meridian Duals,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
Meridian Duals,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,,,,,,,
Meridian Duals,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,94.41,,,,,,,,,,,,
Meridian Duals,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Meridian Duals,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,8.46,,,,,,,,,,,,
Meridian Duals,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,7.01,,,,,,,,,,,,
Meridian Duals,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,,,,,,,
Meridian Duals,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,47.81,,,,,,,,,,,,
Meridian Duals,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
Meridian Duals,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,8.68,,,,,,,,,,,,
Meridian Duals,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,47.63,,,,,,,,,,,,
Meridian Duals,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
Meridian Duals,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,,,,,,,
Meridian Duals,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Meridian Duals,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Meridian Duals,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Meridian Duals,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Meridian Duals,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Meridian Duals,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
Meridian Duals,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Meridian Duals,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Meridian Duals,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,,,,,,,
Meridian Duals,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Meridian Duals,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
Meridian Duals,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
Meridian Duals,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Meridian Duals,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Meridian Duals,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Meridian Duals,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
Meridian Duals,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Meridian Duals,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,16.38,,,,,,,,,,,,
Meridian Duals,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,,,,,,,
Meridian Duals,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,,,,,,,
Meridian Duals,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Meridian Duals,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,,,,,,,
Meridian Duals,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Meridian Duals,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
Meridian Duals,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Meridian Duals,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Meridian Duals,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Meridian Duals,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Meridian Duals,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
Meridian Duals,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Meridian Duals,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,13.76,,,,,,,,,,,,
Meridian Duals,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Meridian Duals,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,16.59,,,,,,,,,,,,
Meridian Duals,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Meridian Duals,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,60,,,,,,,,,,,,
Meridian Duals,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,16.75,,,,,,,,,,,,
Meridian Duals,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Meridian Duals,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
Meridian Duals,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Meridian Duals,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Meridian Duals,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
Meridian Duals,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Meridian Duals,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,16.13,,,,,,,,,,,,
Meridian Duals,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,11.92,,,,,,,,,,,,
Meridian Duals,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Meridian Duals,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Meridian Duals,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Meridian Duals,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Meridian Duals,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Meridian Duals,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Meridian Duals,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Meridian Duals,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Meridian Duals,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Meridian Duals,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,12.6,,,,,,,,,,,,
Meridian Duals,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,17.14,,,,,,,,,,,,
Meridian Duals,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Meridian Duals,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,32.62,,,,,,,,,,,,
Meridian Duals,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,86.96,,,,,,,,,,,,
Meridian Duals,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,78.26,,,,,,,,,,,,
Meridian Duals,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,125.5,,,,,,,,,,,,
Meridian Duals,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,80.37,,,,,,,,,,,,
Meridian Duals,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,801.62,,,,,,,,,,,,
Meridian Duals,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,51.64,,,,,,,,,,,,
Meridian Duals,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,55.89,,,,,,,,,,,,
Meridian Duals,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,209.32,,,,,,,,,,,,
Meridian Duals,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,43.99,,,,,,,,,,,,
Meridian Duals,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,579.48,,,,,,,,,,,,
Meridian Duals,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,161.88,,,,,,,,,,,,
Meridian Duals,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,46.07,,,,,,,,,,,,
Meridian Duals,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,50.5,,,,,,,,,,,,
Meridian Duals,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,148.41,,,,,,,,,,,,
Meridian Duals,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,66.7,,,,,,,,,,,,
Meridian Duals,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,129.33,,,,,,,,,,,,
Meridian Duals,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,165.61,,,,,,,,,,,,
Meridian Duals,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,285.03,,,,,,,,,,,,
Meridian Duals,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,103,,,,,,,,,,,,
Meridian Duals,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,91.16,,,,,,,,,,,,
Meridian Duals,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,50.41,,,,,,,,,,,,
Meridian Duals,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,67.21,,,,,,,,,,,,
Meridian Duals,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,4.02,,,,,,,,,,,,
Meridian Duals,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,3.17,,,,,,,,,,,,
Meridian Duals,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,3.48,,,,,,,,,,,,
Meridian Duals,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,2.25,,,,,,,,,,,,
Meridian Duals,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,2.17,,,,,,,,,,,,
Meridian Duals,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,,,,,,,
Meridian Duals,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,,,,,,,
Meridian Duals,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,4.7,,,,,,,,,,,,
Meridian Duals,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
Meridian Duals,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,3.64,,,,,,,,,,,,
Meridian Duals,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Meridian Duals,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Meridian Duals,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Meridian Duals,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Meridian Duals,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Meridian Duals,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Meridian Duals,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Meridian Duals,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Meridian Duals,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Meridian Duals,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
Meridian Duals,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,,,,,,,
Meridian Duals,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,,,,,,,
Meridian Duals,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,,,,,,,
Meridian Duals,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,,,,,,,
Meridian Duals,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Meridian Duals,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Meridian Duals,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Meridian Duals,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Meridian Duals,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
Meridian Duals,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Meridian Duals,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Meridian Duals,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
Meridian Duals,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
Meridian Duals,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Meridian Duals,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Meridian Duals,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Meridian Duals,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,,,,,,,
Meridian Duals,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
Meridian Duals,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,,,,,,,
Meridian Duals,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,,,,,,,
Meridian Duals,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
Meridian Duals,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,,,,,,,
Meridian Duals,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
Meridian Duals,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,,,,,,,
Meridian Duals,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,,,,,,,
Meridian Duals,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Meridian Duals,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Meridian Duals,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,,,,,,,
Meridian Duals,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Meridian Duals,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,,,,,,,
Meridian Duals,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Meridian Duals,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
Meridian Duals,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,,,,,,,
Meridian Duals,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,,,,,,,
Meridian Duals,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,,,,,,,
Meridian Duals,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,,,,,,,
Meridian Duals,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,,,,,,,
Meridian Duals,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,,,,,,,
Meridian Duals,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Meridian Duals,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Meridian Duals,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,,,,,,,
Meridian Duals,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
Meridian Duals,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Meridian Duals,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
Meridian Duals,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Meridian Duals,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Meridian Duals,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Meridian Duals,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,,,,,,,
Meridian Duals,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
Meridian Duals,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,,,,,,,
Meridian Duals,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,,,,,,,
Meridian Duals,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,,,,,,,
Meridian Duals,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,,,,,,,
Meridian Duals,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,,,,,,,
Meridian Duals,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Meridian Duals,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Meridian Duals,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,,,,,,,
Meridian Duals,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
Meridian Duals,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,,,,,,,
Meridian Duals,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,,,,,,,
Meridian Duals,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,,,,,,,
Meridian Duals,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,,,,,,,
Meridian Duals,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,,,,,,,
Meridian Duals,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,,,,,,,
Meridian Duals,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Meridian Duals,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Meridian Duals,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Meridian Duals,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,,,,,,,
Meridian Duals,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,,,,,,,
Meridian Duals,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,,,,,,,
Meridian Duals,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,,,,,,,
Meridian Duals,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,,,,,,,
Meridian Duals,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,,,,,,,
Meridian Duals,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,,,,,,,
Meridian Duals,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,,,,,,,
Meridian Duals,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Meridian Duals,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
Meridian Duals,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Meridian Duals,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,,,,,,,
Meridian Duals,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Meridian Duals,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Meridian Duals,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
Meridian Duals,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Meridian Duals,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
Meridian Duals,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,,,,,,,
Meridian Duals,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,,,,,,,
Meridian Duals,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Meridian Duals,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,,,,,,,
Meridian Duals,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,,,,,,,
Meridian Duals,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
Meridian Duals,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Meridian Duals,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,,,,,,,
Meridian Duals,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,,,,,,,
Meridian Duals,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,,,,,,,
Meridian Duals,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
Meridian Duals,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
Meridian Duals,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,,,,,,,
Meridian Duals,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,,,,,,,
Meridian Duals,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,,,,,,,
Meridian Duals,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,,,,,,,
Meridian Duals,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
Meridian Duals,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Meridian Duals,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Meridian Duals,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Meridian Duals,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Meridian Duals,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,,,,,,,
Meridian Duals,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
Meridian Duals,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,,,,,,,
Meridian Duals,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Meridian Duals,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Meridian Duals,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Meridian Duals,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Meridian Duals,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
Meridian Duals,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,,,,,,,
Meridian Duals,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Meridian Duals,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Meridian Duals,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
Meridian Duals,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
Meridian Duals,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,,,,,,,
Meridian Duals,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,,,,,,,
Meridian Duals,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
Meridian Duals,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,,,,,,,
Meridian Duals,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
Meridian Duals,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,,,,,,,
Meridian Duals,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,,,,,,,
Meridian Duals,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Meridian Duals,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Meridian Duals,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
Meridian Duals,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,,,,,,,
Meridian Duals,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,,,,,,,
Meridian Duals,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,,,,,,,
Meridian Duals,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Meridian Duals,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Meridian Duals,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,,,,,,,
Meridian Duals,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
Meridian Duals,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Meridian Duals,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
Meridian Duals,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,,,,,,,
Meridian Duals,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Meridian Duals,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Meridian Duals,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Meridian Duals,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Meridian Duals,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
Meridian Duals,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,,,,,,,
Meridian Duals,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,,,,,,,
Meridian Duals,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,,,,,,,
Meridian Duals,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,,,,,,,
Meridian Duals,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,,,,,,,
Meridian Duals,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,,,,,,,
Meridian Duals,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Meridian Duals,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,,,,,,,
Meridian Duals,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,,,,,,,
Meridian Duals,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,,,,,,,
Meridian Duals,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,,,,,,,
Meridian Duals,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,,,,,,,
Meridian Duals,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,,,,,,,
Meridian Duals,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,,,,,,,
Meridian Duals,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,,,,,,,
Meridian Duals,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Meridian Duals,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
Meridian Duals,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Meridian Duals,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Meridian Duals,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
Meridian Duals,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,,,,,,,
Meridian Duals,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,,,,,,,
Meridian Duals,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,,,,,,,
Meridian Duals,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Meridian Duals,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Meridian Duals,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Meridian Duals,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
Meridian Duals,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,,,,,,,
Meridian Duals,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,,,,,,,
Meridian Duals,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Meridian Duals,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Meridian Duals,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Meridian Duals,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,,,,,,,
Meridian Duals,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,,,,,,,
Meridian Duals,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,,,,,,,
Meridian Duals,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,,,,,,,
Meridian Duals,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,,,,,,,
Meridian Duals,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,,,,,,,
Meridian Duals,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Meridian Duals,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Meridian Duals,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Meridian Duals,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Meridian Duals,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Meridian Duals,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Meridian Duals,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Meridian Duals,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,,,,,,,
Meridian Duals,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,,,,,,,
Meridian Duals,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Meridian Duals,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Meridian Duals,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Meridian Duals,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,,,,,,,
Meridian Duals,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Meridian Duals,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,,,,,,,
Meridian Duals,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,,,,,,,
Meridian Duals,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
Meridian Duals,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
Meridian Duals,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
Meridian Duals,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,,,,,,,
Meridian Duals,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,260.5,260.5,,,,,,,,,,,,
Meridian Duals,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,897,897,,,,,,,,,,,,
Meridian Duals,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,,,,,,,
Meridian Duals,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,68.92,68.92,,,,,,,,,,,,
Meridian Duals,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,,,,,,,
Meridian Duals,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,54.3,,,,,,,,,,,,
Meridian Duals,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,"1,487.37","1,487.37",,,,,,,,,,,,
Meridian Duals,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,55.54,,,,,,,,,,,,
Meridian Duals,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,153.5,,,,,,,,,,,,
Meridian Duals,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,69.52,,,,,,,,,,,,
Meridian Duals,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Meridian Duals,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
Meridian Duals,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Meridian Duals,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Meridian Duals,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
Meridian Duals,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Meridian Duals,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Meridian Duals,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,,,,,,,
Meridian Duals,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,,,,,,,
Meridian Duals,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,,,,,,,
Meridian Duals,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,,,,,,,
Meridian Duals,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,,,,,,,
Meridian Duals,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,,,,,,,
Meridian Duals,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Meridian Duals,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,,,,,,,
Meridian Duals,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Meridian Duals,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Meridian Duals,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
Meridian Duals,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
Meridian Duals,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,,,,,,,
Meridian Duals,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,,,,,,,
Meridian Duals,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
Meridian Duals,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,,,,,,,
Meridian Duals,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
Meridian Duals,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
Meridian Duals,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,,,,,,,
Meridian Duals,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,16.49,,,,,,,,,,,,
Meridian Duals,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Meridian Duals,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,38.62,,,,,,,,,,,,
Meridian Duals,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,25.8,,,,,,,,,,,,
Meridian Duals,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Meridian Duals,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,7.78,,,,,,,,,,,,
Meridian Duals,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
Meridian Duals,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,6.23,,,,,,,,,,,,
Meridian Duals,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
Meridian Duals,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,30,,,,,,,,,,,,
Meridian Duals,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Meridian Duals,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Meridian Duals,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,40.75,,,,,,,,,,,,
Meridian Duals,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
Meridian Duals,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
Meridian Duals,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,16.77,,,,,,,,,,,,
Meridian Duals,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,17,,,,,,,,,,,,
Meridian Duals,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Meridian Duals,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,25.48,,,,,,,,,,,,
Meridian Duals,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
Meridian Duals,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Meridian Duals,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,13.87,,,,,,,,,,,,
Meridian Duals,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,22.98,,,,,,,,,,,,
Meridian Duals,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
Meridian Duals,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,19.61,,,,,,,,,,,,
Meridian Duals,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Meridian Duals,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
Meridian Duals,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,9.35,,,,,,,,,,,,
Meridian Duals,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,6.48,,,,,,,,,,,,
Meridian Duals,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,,,,,,,
Meridian Duals,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Meridian Duals,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,25.55,,,,,,,,,,,,
Meridian Duals,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,20.52,,,,,,,,,,,,
Meridian Duals,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
Meridian Duals,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,21.09,,,,,,,,,,,,
Meridian Duals,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,18.97,,,,,,,,,,,,
Meridian Duals,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
Meridian Duals,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,15.9,,,,,,,,,,,,
Meridian Duals,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,16.18,,,,,,,,,,,,
Meridian Duals,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,17.12,,,,,,,,,,,,
Meridian Duals,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,26.58,,,,,,,,,,,,
Meridian Duals,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Meridian Duals,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Meridian Duals,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,4.56,,,,,,,,,,,,
Meridian Duals,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Meridian Duals,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,4.38,,,,,,,,,,,,
Meridian Duals,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,5.32,,,,,,,,,,,,
Meridian Duals,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,,,,,,,
Meridian Duals,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,15.92,,,,,,,,,,,,
Meridian Duals,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
Meridian Duals,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,23.64,,,,,,,,,,,,
Meridian Duals,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
Meridian Duals,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,26.79,,,,,,,,,,,,
Meridian Duals,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
Meridian Duals,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,13.68,,,,,,,,,,,,
Meridian Duals,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
Meridian Duals,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,6.03,,,,,,,,,,,,
Meridian Duals,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,,,,,,,
Meridian Duals,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Meridian Duals,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Meridian Duals,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
Meridian Duals,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Meridian Duals,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,4.88,,,,,,,,,,,,
Meridian Duals,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,12.32,,,,,,,,,,,,
Meridian Duals,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,14.07,,,,,,,,,,,,
Meridian Duals,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,18.96,,,,,,,,,,,,
Meridian Duals,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Meridian Duals,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,9.22,,,,,,,,,,,,
Meridian Duals,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,27.3,,,,,,,,,,,,
Meridian Duals,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,29.08,,,,,,,,,,,,
Meridian Duals,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,25.25,,,,,,,,,,,,
Meridian Duals,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Meridian Duals,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Meridian Duals,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,14.12,,,,,,,,,,,,
Meridian Duals,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,12.67,,,,,,,,,,,,
Meridian Duals,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,4.6,,,,,,,,,,,,
Meridian Duals,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,,,,,,,
Meridian Duals,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
Meridian Duals,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
Meridian Duals,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,4.35,,,,,,,,,,,,
Meridian Duals,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,7.87,,,,,,,,,,,,
Meridian Duals,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
Meridian Duals,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,20.65,,,,,,,,,,,,
Meridian Duals,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,20.28,,,,,,,,,,,,
Meridian Duals,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,27.8,,,,,,,,,,,,
Meridian Duals,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,18.68,,,,,,,,,,,,
Meridian Duals,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,12.41,,,,,,,,,,,,
Meridian Duals,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,22.52,,,,,,,,,,,,
Meridian Duals,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,16.71,,,,,,,,,,,,
Meridian Duals,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
Meridian Duals,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,4.64,,,,,,,,,,,,
Meridian Duals,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,24.09,,,,,,,,,,,,
Meridian Duals,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,6.51,,,,,,,,,,,,
Meridian Duals,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
Meridian Duals,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,11.55,,,,,,,,,,,,
Meridian Duals,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,11.87,,,,,,,,,,,,
Meridian Duals,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,5.12,,,,,,,,,,,,
Meridian Duals,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Meridian Duals,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,9.46,,,,,,,,,,,,
Meridian Duals,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
Meridian Duals,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Meridian Duals,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,,,,,,,
Meridian Duals,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Meridian Duals,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
Meridian Duals,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
Meridian Duals,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
Meridian Duals,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,25.27,,,,,,,,,,,,
Meridian Duals,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,22.23,,,,,,,,,,,,
Meridian Duals,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
Meridian Duals,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Meridian Duals,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Meridian Duals,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Meridian Duals,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,38.5,,,,,,,,,,,,
Meridian Duals,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Meridian Duals,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,22.17,,,,,,,,,,,,
Meridian Duals,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,,,,,,,
Meridian Duals,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,61.5,,,,,,,,,,,,
Meridian Duals,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,18.79,,,,,,,,,,,,
Meridian Duals,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
Meridian Duals,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,32.3,,,,,,,,,,,,
Meridian Duals,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,21.7,,,,,,,,,,,,
Meridian Duals,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,24.18,,,,,,,,,,,,
Meridian Duals,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,24.95,,,,,,,,,,,,
Meridian Duals,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
Meridian Duals,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,14.9,,,,,,,,,,,,
Meridian Duals,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,26.24,,,,,,,,,,,,
Meridian Duals,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,,,,,,,
Meridian Duals,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Meridian Duals,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,22.97,22.97,,,,,,,,,,,,
Meridian Duals,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,,,,,,,
Meridian Duals,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,19.75,,,,,,,,,,,,
Meridian Duals,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,13.63,,,,,,,,,,,,
Meridian Duals,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Meridian Duals,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,18.54,,,,,,,,,,,,
Meridian Duals,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,14.7,,,,,,,,,,,,
Meridian Duals,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
Meridian Duals,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,17.34,,,,,,,,,,,,
Meridian Duals,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
Meridian Duals,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,11.2,,,,,,,,,,,,
Meridian Duals,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,21.07,,,,,,,,,,,,
Meridian Duals,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,,,,,,,
Meridian Duals,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,,,,,,,
Meridian Duals,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,9.3,,,,,,,,,,,,
Meridian Duals,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,16.46,,,,,,,,,,,,
Meridian Duals,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,8.02,,,,,,,,,,,,
Meridian Duals,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,11,,,,,,,,,,,,
Meridian Duals,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Meridian Duals,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,78.77,,,,,,,,,,,,
Meridian Duals,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,,,,,,,
Meridian Duals,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
Meridian Duals,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,,,,,,,
Meridian Duals,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,17.69,,,,,,,,,,,,
Meridian Duals,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,17.63,,,,,,,,,,,,
Meridian Duals,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,14.29,,,,,,,,,,,,
Meridian Duals,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
Meridian Duals,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,17.77,,,,,,,,,,,,
Meridian Duals,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
Meridian Duals,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,5.04,,,,,,,,,,,,
Meridian Duals,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Meridian Duals,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Meridian Duals,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,3.92,,,,,,,,,,,,
Meridian Duals,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,9.7,,,,,,,,,,,,
Meridian Duals,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
Meridian Duals,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
Meridian Duals,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
Meridian Duals,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,13.15,,,,,,,,,,,,
Meridian Duals,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Meridian Duals,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,15.45,,,,,,,,,,,,
Meridian Duals,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Meridian Duals,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,16.76,,,,,,,,,,,,
Meridian Duals,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,18.58,,,,,,,,,,,,
Meridian Duals,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
Meridian Duals,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,16.67,,,,,,,,,,,,
Meridian Duals,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,,,,,,,
Meridian Duals,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
Meridian Duals,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,12.58,,,,,,,,,,,,
Meridian Duals,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,26.89,,,,,,,,,,,,
Meridian Duals,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
Meridian Duals,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,7.86,,,,,,,,,,,,
Meridian Duals,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,20.94,,,,,,,,,,,,
Meridian Duals,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,21.96,,,,,,,,,,,,
Meridian Duals,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Meridian Duals,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Meridian Duals,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,,,,,,,
Meridian Duals,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Meridian Duals,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,,,,,,,
Meridian Duals,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Meridian Duals,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Meridian Duals,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,6.49,,,,,,,,,,,,
Meridian Duals,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,,,,,,,
Meridian Duals,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
Meridian Duals,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,8.8,,,,,,,,,,,,
Meridian Duals,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,9,,,,,,,,,,,,
Meridian Duals,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
Meridian Duals,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
Meridian Duals,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Meridian Duals,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Meridian Duals,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,29.53,,,,,,,,,,,,
Meridian Duals,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,17.92,,,,,,,,,,,,
Meridian Duals,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,22.41,,,,,,,,,,,,
Meridian Duals,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Meridian Duals,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Meridian Duals,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,27.17,,,,,,,,,,,,
Meridian Duals,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,22.65,,,,,,,,,,,,
Meridian Duals,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,24.3,,,,,,,,,,,,
Meridian Duals,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Meridian Duals,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,,,,,,,
Meridian Duals,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,18.4,,,,,,,,,,,,
Meridian Duals,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Meridian Duals,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,11.43,,,,,,,,,,,,
Meridian Duals,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Meridian Duals,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,19.82,,,,,,,,,,,,
Meridian Duals,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Meridian Duals,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,8.74,,,,,,,,,,,,
Meridian Duals,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,8.85,,,,,,,,,,,,
Meridian Duals,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,,,,,,,
Meridian Duals,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,12.8,,,,,,,,,,,,
Meridian Duals,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
Meridian Duals,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
Meridian Duals,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,6.04,,,,,,,,,,,,
Meridian Duals,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,12.79,,,,,,,,,,,,
Meridian Duals,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,19.7,,,,,,,,,,,,
Meridian Duals,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
Meridian Duals,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,20.22,,,,,,,,,,,,
Meridian Duals,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,11.25,,,,,,,,,,,,
Meridian Duals,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Meridian Duals,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
Meridian Duals,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
Meridian Duals,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
Meridian Duals,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,19.32,,,,,,,,,,,,
Meridian Duals,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
Meridian Duals,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
Meridian Duals,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
Meridian Duals,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,46.31,,,,,,,,,,,,
Meridian Duals,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
Meridian Duals,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Meridian Duals,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Meridian Duals,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
Meridian Duals,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,12.75,,,,,,,,,,,,
Meridian Duals,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,10.5,,,,,,,,,,,,
Meridian Duals,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Meridian Duals,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
Meridian Duals,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,6.7,,,,,,,,,,,,
Meridian Duals,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
Meridian Duals,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,26.65,,,,,,,,,,,,
Meridian Duals,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,,,,,,,
Meridian Duals,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,16.26,,,,,,,,,,,,
Meridian Duals,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
Meridian Duals,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Meridian Duals,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,,,,,,,
Meridian Duals,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
Meridian Duals,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,,,,,,,
Meridian Duals,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,17.2,,,,,,,,,,,,
Meridian Duals,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,12.92,,,,,,,,,,,,
Meridian Duals,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
Meridian Duals,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
Meridian Duals,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,13.6,,,,,,,,,,,,
Meridian Duals,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,24.51,,,,,,,,,,,,
Meridian Duals,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,,,,,,,
Meridian Duals,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,27.39,,,,,,,,,,,,
Meridian Duals,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,23.6,,,,,,,,,,,,
Meridian Duals,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
Meridian Duals,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,21.21,,,,,,,,,,,,
Meridian Duals,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
Meridian Duals,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
Meridian Duals,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,29.85,,,,,,,,,,,,
Meridian Duals,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,14.45,,,,,,,,,,,,
Meridian Duals,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Meridian Duals,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Meridian Duals,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,41.28,,,,,,,,,,,,
Meridian Duals,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
Meridian Duals,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
Meridian Duals,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
Meridian Duals,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Meridian Duals,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,3.98,,,,,,,,,,,,
Meridian Duals,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,7.64,,,,,,,,,,,,
Meridian Duals,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
Meridian Duals,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Meridian Duals,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,8.26,,,,,,,,,,,,
Meridian Duals,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
Meridian Duals,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,16.52,,,,,,,,,,,,
Meridian Duals,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Meridian Duals,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,10.73,,,,,,,,,,,,
Meridian Duals,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,4.74,,,,,,,,,,,,
Meridian Duals,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
Meridian Duals,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
Meridian Duals,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,8.44,,,,,,,,,,,,
Meridian Duals,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,,,,,,,
Meridian Duals,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
Meridian Duals,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,14.71,,,,,,,,,,,,
Meridian Duals,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,,,,,,,
Meridian Duals,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,4.76,,,,,,,,,,,,
Meridian Duals,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,4.73,,,,,,,,,,,,
Meridian Duals,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,14.59,,,,,,,,,,,,
Meridian Duals,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,21.27,,,,,,,,,,,,
Meridian Duals,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,21.05,,,,,,,,,,,,
Meridian Duals,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,20.67,,,,,,,,,,,,
Meridian Duals,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,22.81,,,,,,,,,,,,
Meridian Duals,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,20.86,,,,,,,,,,,,
Meridian Duals,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,,,,,,,
Meridian Duals,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,19.38,,,,,,,,,,,,
Meridian Duals,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,,,,,,,
Meridian Duals,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Meridian Duals,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Meridian Duals,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Meridian Duals,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
Meridian Duals,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
Meridian Duals,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,4,,,,,,,,,,,,
Meridian Duals,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,5.61,,,,,,,,,,,,
Meridian Duals,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Meridian Duals,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Meridian Duals,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,17.83,,,,,,,,,,,,
Meridian Duals,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
Meridian Duals,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,29.21,,,,,,,,,,,,
Meridian Duals,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,14.35,,,,,,,,,,,,
Meridian Duals,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
Meridian Duals,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,26.69,,,,,,,,,,,,
Meridian Duals,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,28.1,,,,,,,,,,,,
Meridian Duals,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,14.48,,,,,,,,,,,,
Meridian Duals,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Meridian Duals,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
Meridian Duals,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,87.88,,,,,,,,,,,,
Meridian Duals,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,64.88,,,,,,,,,,,,
Meridian Duals,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,71.23,,,,,,,,,,,,
Meridian Duals,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,36.57,,,,,,,,,,,,
Meridian Duals,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
Meridian Duals,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,,,,,,,
Meridian Duals,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,25.53,,,,,,,,,,,,
Meridian Duals,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
Meridian Duals,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,21.73,,,,,,,,,,,,
Meridian Duals,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
Meridian Duals,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,25.21,,,,,,,,,,,,
Meridian Duals,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,4.81,,,,,,,,,,,,
Meridian Duals,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,5.06,,,,,,,,,,,,
Meridian Duals,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,4.86,,,,,,,,,,,,
Meridian Duals,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,21.26,,,,,,,,,,,,
Meridian Duals,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,18.28,,,,,,,,,,,,
Meridian Duals,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,8.1,,,,,,,,,,,,
Meridian Duals,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
Meridian Duals,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,,,,,,,
Meridian Duals,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Meridian Duals,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Meridian Duals,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Meridian Duals,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Meridian Duals,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,5.49,,,,,,,,,,,,
Meridian Duals,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,25.47,,,,,,,,,,,,
Meridian Duals,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
Meridian Duals,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,,,,,,,
Meridian Duals,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,21.23,,,,,,,,,,,,
Meridian Duals,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
Meridian Duals,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,,,,,,,
Meridian Duals,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,16.06,,,,,,,,,,,,
Meridian Duals,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,6.87,,,,,,,,,,,,
Meridian Duals,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Meridian Duals,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,9.02,,,,,,,,,,,,
Meridian Duals,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
Meridian Duals,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Meridian Duals,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
Meridian Duals,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Meridian Duals,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,18,,,,,,,,,,,,
Meridian Duals,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Meridian Duals,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,5.3,,,,,,,,,,,,
Meridian Duals,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,12.76,,,,,,,,,,,,
Meridian Duals,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,,,,,,,
Meridian Duals,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Meridian Duals,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Meridian Duals,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
Meridian Duals,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,15.76,,,,,,,,,,,,
Meridian Duals,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,12.47,,,,,,,,,,,,
Meridian Duals,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Meridian Duals,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
Meridian Duals,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,9.93,,,,,,,,,,,,
Meridian Duals,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,10.63,,,,,,,,,,,,
Meridian Duals,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,10.09,,,,,,,,,,,,
Meridian Duals,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
Meridian Duals,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,5.13,,,,,,,,,,,,
Meridian Duals,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,5.56,,,,,,,,,,,,
Meridian Duals,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Meridian Duals,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
Meridian Duals,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,5.08,,,,,,,,,,,,
Meridian Duals,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Meridian Duals,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,4.47,,,,,,,,,,,,
Meridian Duals,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
Meridian Duals,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
Meridian Duals,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
Meridian Duals,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,,,,,,,
Meridian Duals,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
Meridian Duals,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
Meridian Duals,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,17.06,,,,,,,,,,,,
Meridian Duals,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,13.72,,,,,,,,,,,,
Meridian Duals,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,17.11,,,,,,,,,,,,
Meridian Duals,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,12.91,,,,,,,,,,,,
Meridian Duals,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,11.39,,,,,,,,,,,,
Meridian Duals,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Meridian Duals,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Meridian Duals,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
Meridian Duals,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Meridian Duals,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,12.7,,,,,,,,,,,,
Meridian Duals,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,4.82,,,,,,,,,,,,
Meridian Duals,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Meridian Duals,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,,,,,,,
Meridian Duals,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,3.43,,,,,,,,,,,,
Meridian Duals,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,5.07,,,,,,,,,,,,
Meridian Duals,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,,,,,,,
Meridian Duals,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
Meridian Duals,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
Meridian Duals,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
Meridian Duals,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Meridian Duals,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Meridian Duals,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,3.02,,,,,,,,,,,,
Meridian Duals,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Meridian Duals,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,,,,,,,
Meridian Duals,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
Meridian Duals,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,2.54,,,,,,,,,,,,
Meridian Duals,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,4.48,,,,,,,,,,,,
Meridian Duals,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,35.74,,,,,,,,,,,,
Meridian Duals,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,11.89,,,,,,,,,,,,
Meridian Duals,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
Meridian Duals,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,20.37,20.37,,,,,,,,,,,,
Meridian Duals,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,12.98,,,,,,,,,,,,
Meridian Duals,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
Meridian Duals,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Meridian Duals,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Meridian Duals,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,20.42,,,,,,,,,,,,
Meridian Duals,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Meridian Duals,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Meridian Duals,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Meridian Duals,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,19.04,,,,,,,,,,,,
Meridian Duals,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Meridian Duals,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Meridian Duals,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Meridian Duals,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
Meridian Duals,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,9.11,,,,,,,,,,,,
Meridian Duals,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
Meridian Duals,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
Meridian Duals,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,11.85,,,,,,,,,,,,
Meridian Duals,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,10.81,,,,,,,,,,,,
Meridian Duals,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
Meridian Duals,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,13.84,,,,,,,,,,,,
Meridian Duals,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
Meridian Duals,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
Meridian Duals,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
Meridian Duals,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Meridian Duals,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Meridian Duals,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,,,,,,,
Meridian Duals,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,4.28,,,,,,,,,,,,
Meridian Duals,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,4.49,,,,,,,,,,,,
Meridian Duals,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
Meridian Duals,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
Meridian Duals,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,80.46,80.46,,,,,,,,,,,,
Meridian Duals,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,12.43,,,,,,,,,,,,
Meridian Duals,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
Meridian Duals,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Meridian Duals,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Meridian Duals,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
Meridian Duals,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
Meridian Duals,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,15.48,,,,,,,,,,,,
Meridian Duals,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,,,,,,,
Meridian Duals,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Meridian Duals,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Meridian Duals,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
Meridian Duals,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,,,,,,,
Meridian Duals,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Meridian Duals,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,4.2,,,,,,,,,,,,
Meridian Duals,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
Meridian Duals,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,,,,,,,
Meridian Duals,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,9.36,,,,,,,,,,,,
Meridian Duals,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,8.87,,,,,,,,,,,,
Meridian Duals,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
Meridian Duals,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,11.84,,,,,,,,,,,,
Meridian Duals,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
Meridian Duals,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,6.88,,,,,,,,,,,,
Meridian Duals,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
Meridian Duals,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
Meridian Duals,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,18.75,,,,,,,,,,,,
Meridian Duals,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,,,,,,,
Meridian Duals,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
Meridian Duals,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,24.91,,,,,,,,,,,,
Meridian Duals,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Meridian Duals,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Meridian Duals,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,4.29,,,,,,,,,,,,
Meridian Duals,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,3.94,,,,,,,,,,,,
Meridian Duals,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,,,,,,,
Meridian Duals,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,9.58,,,,,,,,,,,,
Meridian Duals,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,9.85,,,,,,,,,,,,
Meridian Duals,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Meridian Duals,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,2.7,,,,,,,,,,,,
Meridian Duals,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,5.51,,,,,,,,,,,,
Meridian Duals,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
Meridian Duals,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,6.85,,,,,,,,,,,,
Meridian Duals,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,9.63,,,,,,,,,,,,
Meridian Duals,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
Meridian Duals,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Meridian Duals,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,11.67,,,,,,,,,,,,
Meridian Duals,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,,,,,,,
Meridian Duals,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,7.82,,,,,,,,,,,,
Meridian Duals,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,5.22,,,,,,,,,,,,
Meridian Duals,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,,,,,,,
Meridian Duals,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
Meridian Duals,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Meridian Duals,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,18.37,,,,,,,,,,,,
Meridian Duals,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
Meridian Duals,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
Meridian Duals,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,11.16,,,,,,,,,,,,
Meridian Duals,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
Meridian Duals,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
Meridian Duals,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Meridian Duals,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Meridian Duals,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
Meridian Duals,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
Meridian Duals,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Meridian Duals,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,,,,,,,
Meridian Duals,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
Meridian Duals,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
Meridian Duals,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,8.06,,,,,,,,,,,,
Meridian Duals,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
Meridian Duals,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
Meridian Duals,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,20.32,,,,,,,,,,,,
Meridian Duals,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,10.01,,,,,,,,,,,,
Meridian Duals,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Meridian Duals,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Meridian Duals,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
Meridian Duals,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Meridian Duals,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
Meridian Duals,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Meridian Duals,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Meridian Duals,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,,,,,,,
Meridian Duals,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
Meridian Duals,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,25.57,,,,,,,,,,,,
Meridian Duals,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Meridian Duals,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Meridian Duals,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Meridian Duals,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Meridian Duals,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Meridian Duals,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Meridian Duals,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
Meridian Duals,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Meridian Duals,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,14.99,,,,,,,,,,,,
Meridian Duals,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
Meridian Duals,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
Meridian Duals,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,23.13,,,,,,,,,,,,
Meridian Duals,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
Meridian Duals,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,,,,,,,
Meridian Duals,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,24.37,,,,,,,,,,,,
Meridian Duals,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,22.34,,,,,,,,,,,,
Meridian Duals,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,29.35,,,,,,,,,,,,
Meridian Duals,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,15.59,,,,,,,,,,,,
Meridian Duals,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,21.41,,,,,,,,,,,,
Meridian Duals,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Meridian Duals,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,23.57,,,,,,,,,,,,
Meridian Duals,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
Meridian Duals,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,10.39,,,,,,,,,,,,
Meridian Duals,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,,,,,,,
Meridian Duals,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,49.03,,,,,,,,,,,,
Meridian Duals,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Meridian Duals,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
Meridian Duals,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Meridian Duals,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Meridian Duals,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,46.98,,,,,,,,,,,,
Meridian Duals,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
Meridian Duals,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,77.78,,,,,,,,,,,,
Meridian Duals,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,14.55,,,,,,,,,,,,
Meridian Duals,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,16.91,,,,,,,,,,,,
Meridian Duals,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
Meridian Duals,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,,,,,,,
Meridian Duals,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,11.54,,,,,,,,,,,,
Meridian Duals,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,10.64,,,,,,,,,,,,
Meridian Duals,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,6.14,,,,,,,,,,,,
Meridian Duals,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,5.67,,,,,,,,,,,,
Meridian Duals,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,61.98,,,,,,,,,,,,
Meridian Duals,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,,,,,,,
Meridian Duals,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
Meridian Duals,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Meridian Duals,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,4.4,,,,,,,,,,,,
Meridian Duals,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Meridian Duals,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Meridian Duals,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Meridian Duals,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Meridian Duals,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Meridian Duals,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Meridian Duals,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
Meridian Duals,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
Meridian Duals,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,13.38,,,,,,,,,,,,
Meridian Duals,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,,,,,,,
Meridian Duals,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
Meridian Duals,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
Meridian Duals,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,11.82,,,,,,,,,,,,
Meridian Duals,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,12.68,,,,,,,,,,,,
Meridian Duals,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,11.47,,,,,,,,,,,,
Meridian Duals,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,12.12,,,,,,,,,,,,
Meridian Duals,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
Meridian Duals,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Meridian Duals,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Meridian Duals,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,15.21,,,,,,,,,,,,
Meridian Duals,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,13.03,,,,,,,,,,,,
Meridian Duals,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
Meridian Duals,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Meridian Duals,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,18.14,,,,,,,,,,,,
Meridian Duals,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Meridian Duals,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,14.16,,,,,,,,,,,,
Meridian Duals,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Meridian Duals,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,,,,,,,
Meridian Duals,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Meridian Duals,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,13.01,,,,,,,,,,,,
Meridian Duals,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,,,,,,,
Meridian Duals,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,9.09,,,,,,,,,,,,
Meridian Duals,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,14,,,,,,,,,,,,
Meridian Duals,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Meridian Duals,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,17.16,,,,,,,,,,,,
Meridian Duals,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Meridian Duals,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Meridian Duals,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,13.79,,,,,,,,,,,,
Meridian Duals,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,8.89,,,,,,,,,,,,
Meridian Duals,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,13.52,,,,,,,,,,,,
Meridian Duals,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,13.71,,,,,,,,,,,,
Meridian Duals,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Meridian Duals,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,11.77,,,,,,,,,,,,
Meridian Duals,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Meridian Duals,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
Meridian Duals,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
Meridian Duals,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
Meridian Duals,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,13.55,,,,,,,,,,,,
Meridian Duals,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,,,,,,,
Meridian Duals,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
Meridian Duals,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Meridian Duals,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,16.2,,,,,,,,,,,,
Meridian Duals,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Meridian Duals,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
Meridian Duals,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,,,,,,,
Meridian Duals,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
Meridian Duals,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
Meridian Duals,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,15.03,,,,,,,,,,,,
Meridian Duals,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
Meridian Duals,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,,,,,,,
Meridian Duals,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Meridian Duals,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,18.23,,,,,,,,,,,,
Meridian Duals,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Meridian Duals,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Meridian Duals,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,24.48,,,,,,,,,,,,
Meridian Duals,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,14.8,,,,,,,,,,,,
Meridian Duals,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Meridian Duals,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
Meridian Duals,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
Meridian Duals,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,,,,,,,
Meridian Duals,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Meridian Duals,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Meridian Duals,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Meridian Duals,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Meridian Duals,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Meridian Duals,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Meridian Duals,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,15.91,,,,,,,,,,,,
Meridian Duals,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,14.27,,,,,,,,,,,,
Meridian Duals,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
Meridian Duals,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,189.51,,,,,,,,,,,,
Meridian Duals,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,47.59,,,,,,,,,,,,
Meridian Duals,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,78.65,,,,,,,,,,,,
Meridian Duals,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,29.68,,,,,,,,,,,,
Meridian Duals,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
Meridian Duals,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
Meridian Duals,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,,,,,,,
Meridian Duals,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,106.14,,,,,,,,,,,,
Meridian Duals,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,36.56,,,,,,,,,,,,
Meridian Duals,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,,,,,,,
Meridian Duals,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,,,,,,,
Meridian Duals,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Meridian Duals,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Meridian Duals,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,,,,,,,
Meridian Duals,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,,,,,,,
Meridian Duals,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,,,,,,,
Meridian Duals,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,,,,,,,
Meridian Duals,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,,,,,,,
Meridian Duals,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Meridian Duals,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,8.77,,,,,,,,,,,,
Meridian Duals,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Meridian Duals,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,16.84,,,,,,,,,,,,
Meridian Duals,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,6.68,,,,,,,,,,,,
Meridian Duals,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Meridian Duals,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Meridian Duals,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Meridian Duals,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,8.62,,,,,,,,,,,,
Meridian Duals,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
Meridian Duals,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
Meridian Duals,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
Meridian Duals,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
Meridian Duals,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
Meridian Duals,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,6.63,,,,,,,,,,,,
Meridian Duals,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,27.07,27.07,,,,,,,,,,,,
Meridian Duals,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
Meridian Duals,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,8.09,,,,,,,,,,,,
Meridian Duals,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Meridian Duals,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
Meridian Duals,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,20.46,,,,,,,,,,,,
Meridian Duals,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Meridian Duals,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Meridian Duals,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,15.39,,,,,,,,,,,,
Meridian Duals,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,19.6,,,,,,,,,,,,
Meridian Duals,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,10.8,,,,,,,,,,,,
Meridian Duals,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,14.61,,,,,,,,,,,,
Meridian Duals,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
Meridian Duals,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
Meridian Duals,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Meridian Duals,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
Meridian Duals,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,,,,,,,
Meridian Duals,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
Meridian Duals,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Meridian Duals,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,11.3,,,,,,,,,,,,
Meridian Duals,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Meridian Duals,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Meridian Duals,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Meridian Duals,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
Meridian Duals,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,8.9,,,,,,,,,,,,
Meridian Duals,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Meridian Duals,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,7.48,,,,,,,,,,,,
Meridian Duals,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Meridian Duals,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,,,,,,,
Meridian Duals,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,40.17,,,,,,,,,,,,
Meridian Duals,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,,,,,,,
Meridian Duals,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
Meridian Duals,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,15.02,,,,,,,,,,,,
Meridian Duals,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Meridian Duals,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,5.39,,,,,,,,,,,,
Meridian Duals,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
Meridian Duals,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Meridian Duals,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
Meridian Duals,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Meridian Duals,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,19.74,,,,,,,,,,,,
Meridian Duals,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
Meridian Duals,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Meridian Duals,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,20.2,,,,,,,,,,,,
Meridian Duals,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
Meridian Duals,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Meridian Duals,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,,,,,,,
Meridian Duals,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Meridian Duals,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
Meridian Duals,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Meridian Duals,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Meridian Duals,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Meridian Duals,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,15.6,,,,,,,,,,,,
Meridian Duals,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,16.43,,,,,,,,,,,,
Meridian Duals,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Meridian Duals,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,60.8,60.8,,,,,,,,,,,,
Meridian Duals,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,12.18,,,,,,,,,,,,
Meridian Duals,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Meridian Duals,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,16.1,,,,,,,,,,,,
Meridian Duals,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
Meridian Duals,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Meridian Duals,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,13.82,,,,,,,,,,,,
Meridian Duals,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
Meridian Duals,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Meridian Duals,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,14.38,,,,,,,,,,,,
Meridian Duals,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Meridian Duals,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
Meridian Duals,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
Meridian Duals,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Meridian Duals,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,,,,,,,
Meridian Duals,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Meridian Duals,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
Meridian Duals,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,,,,,,,
Meridian Duals,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,21.9,,,,,,,,,,,,
Meridian Duals,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,14.13,,,,,,,,,,,,
Meridian Duals,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,13.91,,,,,,,,,,,,
Meridian Duals,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,16.81,,,,,,,,,,,,
Meridian Duals,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,10.51,,,,,,,,,,,,
Meridian Duals,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,55.74,,,,,,,,,,,,
Meridian Duals,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Meridian Duals,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,22.75,,,,,,,,,,,,
Meridian Duals,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,53.47,,,,,,,,,,,,
Meridian Duals,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,,,,,,,
Meridian Duals,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
Meridian Duals,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Meridian Duals,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,,,,,,,
Meridian Duals,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,,,,,,,
Meridian Duals,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,,,,,,,
Meridian Duals,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
Meridian Duals,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Meridian Duals,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Meridian Duals,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,31.22,,,,,,,,,,,,
Meridian Duals,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,29.8,,,,,,,,,,,,
Meridian Duals,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
Meridian Duals,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Meridian Duals,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
Meridian Duals,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Meridian Duals,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
Meridian Duals,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,85.1,,,,,,,,,,,,
Meridian Duals,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
Meridian Duals,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,58.62,,,,,,,,,,,,
Meridian Duals,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Meridian Duals,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,48.24,,,,,,,,,,,,
Meridian Duals,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
Meridian Duals,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,41.68,,,,,,,,,,,,
Meridian Duals,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,27.29,,,,,,,,,,,,
Meridian Duals,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,302.62,302.62,,,,,,,,,,,,
Meridian Duals,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
Meridian Duals,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,40.55,,,,,,,,,,,,
Meridian Duals,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Meridian Duals,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,,,,,,,
Meridian Duals,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Meridian Duals,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
Meridian Duals,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Meridian Duals,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Meridian Duals,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Meridian Duals,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
Meridian Duals,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Meridian Duals,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,43.67,,,,,,,,,,,,
Meridian Duals,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
Meridian Duals,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,12.73,,,,,,,,,,,,
Meridian Duals,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Meridian Duals,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,16.55,,,,,,,,,,,,
Meridian Duals,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,32.77,,,,,,,,,,,,
Meridian Duals,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,13.1,,,,,,,,,,,,
Meridian Duals,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Meridian Duals,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,21.76,,,,,,,,,,,,
Meridian Duals,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,35.29,,,,,,,,,,,,
Meridian Duals,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,24.56,,,,,,,,,,,,
Meridian Duals,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,16.53,,,,,,,,,,,,
Meridian Duals,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Meridian Duals,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,130.35,,,,,,,,,,,,
Meridian Duals,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Meridian Duals,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Meridian Duals,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,,,,,,,
Meridian Duals,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Meridian Duals,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,12.22,,,,,,,,,,,,
Meridian Duals,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,,,,,,,
Meridian Duals,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Meridian Duals,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Meridian Duals,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Meridian Duals,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,7.99,,,,,,,,,,,,
Meridian Duals,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
Meridian Duals,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,23.04,,,,,,,,,,,,
Meridian Duals,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,50.56,50.56,,,,,,,,,,,,
Meridian Duals,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Meridian Duals,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Meridian Duals,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,27.64,,,,,,,,,,,,
Meridian Duals,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,24.03,,,,,,,,,,,,
Meridian Duals,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,14.65,,,,,,,,,,,,
Meridian Duals,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Meridian Duals,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,42.22,,,,,,,,,,,,
Meridian Duals,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Meridian Duals,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Meridian Duals,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,25.37,,,,,,,,,,,,
Meridian Duals,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,26.61,,,,,,,,,,,,
Meridian Duals,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,116.49,,,,,,,,,,,,
Meridian Duals,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,140.73,,,,,,,,,,,,
Meridian Duals,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,150.3,,,,,,,,,,,,
Meridian Duals,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,143.75,,,,,,,,,,,,
Meridian Duals,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,147.52,,,,,,,,,,,,
Meridian Duals,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,13.07,,,,,,,,,,,,
Meridian Duals,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
Meridian Duals,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Meridian Duals,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Meridian Duals,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Meridian Duals,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,264.34,,,,,,,,,,,,
Meridian Duals,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,125.49,,,,,,,,,,,,
Meridian Duals,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,150.29,,,,,,,,,,,,
Meridian Duals,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,144.61,,,,,,,,,,,,
Meridian Duals,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,188.57,,,,,,,,,,,,
Meridian Duals,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,173.66,,,,,,,,,,,,
Meridian Duals,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,21.42,,,,,,,,,,,,
Meridian Duals,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,40.7,,,,,,,,,,,,
Meridian Duals,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,34.81,,,,,,,,,,,,
Meridian Duals,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,42.38,,,,,,,,,,,,
Meridian Duals,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,51.19,,,,,,,,,,,,
Meridian Duals,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,33.47,,,,,,,,,,,,
Meridian Duals,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,,,,,,,
Meridian Duals,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,26.91,,,,,,,,,,,,
Meridian Duals,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,34.43,,,,,,,,,,,,
Meridian Duals,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Meridian Duals,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Meridian Duals,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
Meridian Duals,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
Meridian Duals,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,4.72,,,,,,,,,,,,
Meridian Duals,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,5.6,,,,,,,,,,,,
Meridian Duals,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Meridian Duals,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,7.33,,,,,,,,,,,,
Meridian Duals,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
Meridian Duals,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,4.85,,,,,,,,,,,,
Meridian Duals,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,5.79,,,,,,,,,,,,
Meridian Duals,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,9.84,,,,,,,,,,,,
Meridian Duals,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
Meridian Duals,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,12.31,,,,,,,,,,,,
Meridian Duals,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Meridian Duals,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
Meridian Duals,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,,,,,,,
Meridian Duals,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
Meridian Duals,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,10.38,,,,,,,,,,,,
Meridian Duals,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
Meridian Duals,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
Meridian Duals,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Meridian Duals,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Meridian Duals,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Meridian Duals,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
Meridian Duals,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,,,,,,,
Meridian Duals,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Meridian Duals,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
Meridian Duals,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,,,,,,,
Meridian Duals,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Meridian Duals,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Meridian Duals,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,,,,,,,
Meridian Duals,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,,,,,,,
Meridian Duals,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Meridian Duals,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Meridian Duals,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Meridian Duals,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Meridian Duals,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Meridian Duals,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Meridian Duals,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,,,,,,,
Meridian Duals,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Meridian Duals,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
Meridian Duals,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
Meridian Duals,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,,,,,,,
Meridian Duals,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,,,,,,,
Meridian Duals,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Meridian Duals,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,,,,,,,
Meridian Duals,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,,,,,,,
Meridian Duals,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Meridian Duals,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,,,,,,,
Meridian Duals,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
Meridian Duals,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,,,,,,,
Meridian Duals,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,,,,,,,
Meridian Duals,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,,,,,,,
Meridian Duals,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Meridian Duals,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,,,,,,,
Meridian Duals,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
Meridian Duals,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,,,,,,,
Meridian Duals,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
Meridian Duals,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
Meridian Duals,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
Meridian Duals,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
Meridian Duals,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,,,,,,,
Meridian Duals,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
Meridian Duals,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
Meridian Duals,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
Meridian Duals,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
Meridian Duals,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Meridian Duals,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Meridian Duals,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Meridian Duals,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Meridian Duals,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Meridian Duals,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,,,,,,,
Meridian Duals,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,,,,,,,
Meridian Duals,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Meridian Duals,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
Meridian Duals,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,,,,,,,
Meridian Duals,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
Meridian Duals,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Meridian Duals,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Meridian Duals,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Meridian Duals,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Meridian Duals,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,,,,,,,
Meridian Duals,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,,,,,,,
Meridian Duals,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,,,,,,,
Meridian Duals,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,,,,,,,
Meridian Duals,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
Meridian Duals,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Meridian Duals,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,,,,,,,
Meridian Duals,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Meridian Duals,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,,,,,,,
Meridian Duals,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,,,,,,,
Meridian Duals,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Meridian Duals,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Meridian Duals,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Meridian Duals,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Meridian Duals,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Meridian Duals,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Meridian Duals,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,,,,,,,
Meridian Duals,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Meridian Duals,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,,,,,,,
Meridian Duals,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Meridian Duals,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,,,,,,,
Meridian Duals,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
Meridian Duals,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
Meridian Duals,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
Meridian Duals,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
Meridian Duals,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Meridian Duals,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
Meridian Duals,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,,,,,,,
Meridian Duals,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Meridian Duals,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,,,,,,,
Meridian Duals,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,,,,,,,
Meridian Duals,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,,,,,,,
Meridian Duals,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
Meridian Duals,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,,,,,,,
Meridian Duals,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Meridian Duals,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,,,,,,,
Meridian Duals,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Meridian Duals,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Meridian Duals,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,,,,,,,
Meridian Duals,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,,,,,,,
Meridian Duals,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Meridian Duals,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,,,,,,,
Meridian Duals,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,,,,,,,
Meridian Duals,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Meridian Duals,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
Meridian Duals,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,,,,,,,
Meridian Duals,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,,,,,,,
Meridian Duals,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
Meridian Duals,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,,,,,,,
Meridian Duals,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,,,,,,,
Meridian Duals,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,,,,,,,
Meridian Duals,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Meridian Duals,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,,,,,,,
Meridian Duals,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,,,,,,,
Meridian Duals,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,,,,,,,
Meridian Duals,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,,,,,,,
Meridian Duals,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,,,,,,,
Meridian Duals,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Meridian Duals,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Meridian Duals,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,,,,,,,
Meridian Duals,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Meridian Duals,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Meridian Duals,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Meridian Duals,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Meridian Duals,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Meridian Duals,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Meridian Duals,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,,,,,,,
Meridian Duals,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Meridian Duals,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
Meridian Duals,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
Meridian Duals,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
Meridian Duals,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,,,,,,,
Meridian Duals,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Meridian Duals,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Meridian Duals,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Meridian Duals,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Meridian Duals,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Meridian Duals,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Meridian Duals,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Meridian Duals,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Meridian Duals,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Meridian Duals,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Meridian Duals,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
Meridian Duals,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,,,,,,,
Meridian Duals,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,,,,,,,
Meridian Duals,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
Meridian Duals,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,,,,,,,
Meridian Duals,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,6.5,,,,,,,,,,,,
Meridian Duals,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,19.31,,,,,,,,,,,,
Meridian Duals,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
Meridian Duals,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,27.05,,,,,,,,,,,,
Meridian Duals,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,43.97,,,,,,,,,,,,
Meridian Duals,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,26.49,,,,,,,,,,,,
Meridian Duals,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Meridian Duals,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,31.94,,,,,,,,,,,,
Meridian Duals,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
Meridian Duals,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Meridian Duals,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Meridian Duals,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,,,,,,,
Meridian Duals,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,,,,,,,
Meridian Duals,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Meridian Duals,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
Meridian Duals,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,,,,,,,
Meridian Duals,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
Meridian Duals,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Meridian Duals,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Meridian Duals,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,,,,,,,
Meridian Duals,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,,,,,,,
Meridian Duals,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Meridian Duals,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,,,,,,,
Meridian Duals,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Meridian Duals,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Meridian Duals,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Meridian Duals,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Meridian Duals,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Meridian Duals,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Meridian Duals,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
Meridian Duals,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Meridian Duals,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,5.83,,,,,,,,,,,,
Meridian Duals,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Meridian Duals,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
Meridian Duals,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Meridian Duals,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
Meridian Duals,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
Meridian Duals,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Meridian Duals,,,,All Other,Straight Discount,30.00%,OP,,,,,,,,,,,,,,
Meridian Medicaid,DRG,11,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$38,043.18 ",IP,"38,043.18","38,043.18",,,,,,,,,,,,
Meridian Medicaid,DRG,12,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$40,281.56 ",IP,"40,281.56","40,281.56",,,,,,,,,,,,
Meridian Medicaid,DRG,13,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$42,053.29 ",IP,"42,053.29","42,053.29",,,,,,,,,,,,
Meridian Medicaid,DRG,14,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$78,175.26 ",IP,"78,175.26","78,175.26",,,,,,,,,,,,
Meridian Medicaid,DRG,21,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$45,599.51 ",IP,"45,599.51","45,599.51",,,,,,,,,,,,
Meridian Medicaid,DRG,22,HEART &/OR LUNG TRANSPLANT,,Relative Weights,"$58,026.75 ",IP,"58,026.75","58,026.75",,,,,,,,,,,,
Meridian Medicaid,DRG,23,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$74,400.53 ",IP,"74,400.53","74,400.53",,,,,,,,,,,,
Meridian Medicaid,DRG,24,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$107,953.54 ",IP,"107,953.54","107,953.54",,,,,,,,,,,,
Meridian Medicaid,DRG,41,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$33,014.21 ",IP,"33,014.21","33,014.21",,,,,,,,,,,,
Meridian Medicaid,DRG,42,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$37,820.51 ",IP,"37,820.51","37,820.51",,,,,,,,,,,,
Meridian Medicaid,DRG,43,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$49,052.96 ",IP,"49,052.96","49,052.96",,,,,,,,,,,,
Meridian Medicaid,DRG,44,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$72,921.22 ",IP,"72,921.22","72,921.22",,,,,,,,,,,,
Meridian Medicaid,DRG,51,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$23,684.08 ",IP,"23,684.08","23,684.08",,,,,,,,,,,,
Meridian Medicaid,DRG,52,TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,,Relative Weights,"$26,315.91 ",IP,"26,315.91","26,315.91",,,,,,,,,,,,
Meridian Medicaid,DRG,53,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$36,197.91 ",IP,"36,197.91","36,197.91",,,,,,,,,,,,
Meridian Medicaid,DRG,54,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$48,934.75 ",IP,"48,934.75","48,934.75",,,,,,,,,,,,
Meridian Medicaid,DRG,61,PANCREAS TRANSPLANT,,Relative Weights,"$40,520.03 ",IP,"40,520.03","40,520.03",,,,,,,,,,,,
Meridian Medicaid,DRG,62,PANCREAS TRANSPLANT,,Relative Weights,"$45,022.22 ",IP,"45,022.22","45,022.22",,,,,,,,,,,,
Meridian Medicaid,DRG,63,PANCREAS TRANSPLANT,,Relative Weights,"$47,794.94 ",IP,"47,794.94","47,794.94",,,,,,,,,,,,
Meridian Medicaid,DRG,64,PANCREAS TRANSPLANT,,Relative Weights,"$66,459.33 ",IP,"66,459.33","66,459.33",,,,,,,,,,,,
Meridian Medicaid,DRG,71,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$38,434.91 ",IP,"38,434.91","38,434.91",,,,,,,,,,,,
Meridian Medicaid,DRG,72,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$48,059.19 ",IP,"48,059.19","48,059.19",,,,,,,,,,,,
Meridian Medicaid,DRG,73,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$59,827.69 ",IP,"59,827.69","59,827.69",,,,,,,,,,,,
Meridian Medicaid,DRG,74,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$99,672.84 ",IP,"99,672.84","99,672.84",,,,,,,,,,,,
Meridian Medicaid,DRG,81,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$22,091.37 ",IP,"22,091.37","22,091.37",,,,,,,,,,,,
Meridian Medicaid,DRG,82,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$27,118.96 ",IP,"27,118.96","27,118.96",,,,,,,,,,,,
Meridian Medicaid,DRG,83,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$32,175.76 ",IP,"32,175.76","32,175.76",,,,,,,,,,,,
Meridian Medicaid,DRG,84,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$51,576.54 ",IP,"51,576.54","51,576.54",,,,,,,,,,,,
Meridian Medicaid,DRG,91,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$27,699.69 ",IP,"27,699.69","27,699.69",,,,,,,,,,,,
Meridian Medicaid,DRG,92,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$30,776.86 ",IP,"30,776.86","30,776.86",,,,,,,,,,,,
Meridian Medicaid,DRG,93,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$36,358.72 ",IP,"36,358.72","36,358.72",,,,,,,,,,,,
Meridian Medicaid,DRG,94,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$79,300.63 ",IP,"79,300.63","79,300.63",,,,,,,,,,,,
Meridian Medicaid,DRG,101,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$4,104.27 ",IP,"4,104.27","4,104.27",,,,,,,,,,,,
Meridian Medicaid,DRG,102,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,,,,,,,
Meridian Medicaid,DRG,103,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$12,592.86 ",IP,"12,592.86","12,592.86",,,,,,,,,,,,
Meridian Medicaid,DRG,104,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$37,584.09 ",IP,"37,584.09","37,584.09",,,,,,,,,,,,
Meridian Medicaid,DRG,201,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$9,991.61 ",IP,"9,991.61","9,991.61",,,,,,,,,,,,
Meridian Medicaid,DRG,202,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$11,868.15 ",IP,"11,868.15","11,868.15",,,,,,,,,,,,
Meridian Medicaid,DRG,203,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$16,002.32 ",IP,"16,002.32","16,002.32",,,,,,,,,,,,
Meridian Medicaid,DRG,204,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$28,673.87 ",IP,"28,673.87","28,673.87",,,,,,,,,,,,
Meridian Medicaid,DRG,211,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$9,882.68 ",IP,"9,882.68","9,882.68",,,,,,,,,,,,
Meridian Medicaid,DRG,212,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$13,243.69 ",IP,"13,243.69","13,243.69",,,,,,,,,,,,
Meridian Medicaid,DRG,213,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$18,834.48 ",IP,"18,834.48","18,834.48",,,,,,,,,,,,
Meridian Medicaid,DRG,214,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$27,671.86 ",IP,"27,671.86","27,671.86",,,,,,,,,,,,
Meridian Medicaid,DRG,221,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$6,449.86 ",IP,"6,449.86","6,449.86",,,,,,,,,,,,
Meridian Medicaid,DRG,222,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$7,492.76 ",IP,"7,492.76","7,492.76",,,,,,,,,,,,
Meridian Medicaid,DRG,223,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$10,628.01 ",IP,"10,628.01","10,628.01",,,,,,,,,,,,
Meridian Medicaid,DRG,224,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$25,450.32 ",IP,"25,450.32","25,450.32",,,,,,,,,,,,
Meridian Medicaid,DRG,231,SPINAL PROCEDURES,,Relative Weights,"$7,646.71 ",IP,"7,646.71","7,646.71",,,,,,,,,,,,
Meridian Medicaid,DRG,232,SPINAL PROCEDURES,,Relative Weights,"$9,630.12 ",IP,"9,630.12","9,630.12",,,,,,,,,,,,
Meridian Medicaid,DRG,233,SPINAL PROCEDURES,,Relative Weights,"$16,000.26 ",IP,"16,000.26","16,000.26",,,,,,,,,,,,
Meridian Medicaid,DRG,234,SPINAL PROCEDURES,,Relative Weights,"$29,075.91 ",IP,"29,075.91","29,075.91",,,,,,,,,,,,
Meridian Medicaid,DRG,241,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$5,741.65 ",IP,"5,741.65","5,741.65",,,,,,,,,,,,
Meridian Medicaid,DRG,242,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$6,726.14 ",IP,"6,726.14","6,726.14",,,,,,,,,,,,
Meridian Medicaid,DRG,243,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$13,747.79 ",IP,"13,747.79","13,747.79",,,,,,,,,,,,
Meridian Medicaid,DRG,244,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$24,782.31 ",IP,"24,782.31","24,782.31",,,,,,,,,,,,
Meridian Medicaid,DRG,261,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,157.39 ",IP,"7,157.39","7,157.39",,,,,,,,,,,,
Meridian Medicaid,DRG,262,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$8,935.31 ",IP,"8,935.31","8,935.31",,,,,,,,,,,,
Meridian Medicaid,DRG,263,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$12,455.76 ",IP,"12,455.76","12,455.76",,,,,,,,,,,,
Meridian Medicaid,DRG,264,OTHER NERVOUS SYSTEM & RELATED PROCEDURES,,Relative Weights,"$22,781.03 ",IP,"22,781.03","22,781.03",,,,,,,,,,,,
Meridian Medicaid,DRG,401,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,482.55 ",IP,"5,482.55","5,482.55",,,,,,,,,,,,
Meridian Medicaid,DRG,402,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,877.72 ",IP,"5,877.72","5,877.72",,,,,,,,,,,,
Meridian Medicaid,DRG,403,SPINAL DISORDERS and INJURIES,,Relative Weights,"$8,545.98 ",IP,"8,545.98","8,545.98",,,,,,,,,,,,
Meridian Medicaid,DRG,404,SPINAL DISORDERS and INJURIES,,Relative Weights,"$17,945.87 ",IP,"17,945.87","17,945.87",,,,,,,,,,,,
Meridian Medicaid,DRG,411,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,340.00 ",IP,"4,340.00","4,340.00",,,,,,,,,,,,
Meridian Medicaid,DRG,412,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,441.02 ",IP,"4,441.02","4,441.02",,,,,,,,,,,,
Meridian Medicaid,DRG,413,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$5,802.81 ",IP,"5,802.81","5,802.81",,,,,,,,,,,,
Meridian Medicaid,DRG,414,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$8,029.51 ",IP,"8,029.51","8,029.51",,,,,,,,,,,,
Meridian Medicaid,DRG,421,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,328.02 ",IP,"3,328.02","3,328.02",,,,,,,,,,,,
Meridian Medicaid,DRG,422,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,814.25 ",IP,"3,814.25","3,814.25",,,,,,,,,,,,
Meridian Medicaid,DRG,423,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$5,381.53 ",IP,"5,381.53","5,381.53",,,,,,,,,,,,
Meridian Medicaid,DRG,424,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$12,544.07 ",IP,"12,544.07","12,544.07",,,,,,,,,,,,
Meridian Medicaid,DRG,431,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$4,040.70 ",IP,"4,040.70","4,040.70",,,,,,,,,,,,
Meridian Medicaid,DRG,432,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$5,014.88 ",IP,"5,014.88","5,014.88",,,,,,,,,,,,
Meridian Medicaid,DRG,433,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$7,268.72 ",IP,"7,268.72","7,268.72",,,,,,,,,,,,
Meridian Medicaid,DRG,434,MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,,Relative Weights,"$15,032.61 ",IP,"15,032.61","15,032.61",,,,,,,,,,,,
Meridian Medicaid,DRG,441,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$3,968.19 ",IP,"3,968.19","3,968.19",,,,,,,,,,,,
Meridian Medicaid,DRG,442,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$4,927.25 ",IP,"4,927.25","4,927.25",,,,,,,,,,,,
Meridian Medicaid,DRG,443,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$6,702.77 ",IP,"6,702.77","6,702.77",,,,,,,,,,,,
Meridian Medicaid,DRG,444,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$9,326.01 ",IP,"9,326.01","9,326.01",,,,,,,,,,,,
Meridian Medicaid,DRG,451,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$3,612.20 ",IP,"3,612.20","3,612.20",,,,,,,,,,,,
Meridian Medicaid,DRG,452,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$4,429.34 ",IP,"4,429.34","4,429.34",,,,,,,,,,,,
Meridian Medicaid,DRG,453,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$5,951.60 ",IP,"5,951.60","5,951.60",,,,,,,,,,,,
Meridian Medicaid,DRG,454,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$10,976.10 ",IP,"10,976.10","10,976.10",,,,,,,,,,,,
Meridian Medicaid,DRG,461,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$3,784.70 ",IP,"3,784.70","3,784.70",,,,,,,,,,,,
Meridian Medicaid,DRG,462,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$4,264.40 ",IP,"4,264.40","4,264.40",,,,,,,,,,,,
Meridian Medicaid,DRG,463,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$5,292.53 ",IP,"5,292.53","5,292.53",,,,,,,,,,,,
Meridian Medicaid,DRG,464,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$10,621.82 ",IP,"10,621.82","10,621.82",,,,,,,,,,,,
Meridian Medicaid,DRG,471,TRANSIENT ISCHEMIA,,Relative Weights,"$3,321.15 ",IP,"3,321.15","3,321.15",,,,,,,,,,,,
Meridian Medicaid,DRG,472,TRANSIENT ISCHEMIA,,Relative Weights,"$3,597.42 ",IP,"3,597.42","3,597.42",,,,,,,,,,,,
Meridian Medicaid,DRG,473,TRANSIENT ISCHEMIA,,Relative Weights,"$4,242.41 ",IP,"4,242.41","4,242.41",,,,,,,,,,,,
Meridian Medicaid,DRG,474,TRANSIENT ISCHEMIA,,Relative Weights,"$7,719.21 ",IP,"7,719.21","7,719.21",,,,,,,,,,,,
Meridian Medicaid,DRG,481,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,400.87 ",IP,"3,400.87","3,400.87",,,,,,,,,,,,
Meridian Medicaid,DRG,482,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,627.32 ",IP,"3,627.32","3,627.32",,,,,,,,,,,,
Meridian Medicaid,DRG,483,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$4,545.48 ",IP,"4,545.48","4,545.48",,,,,,,,,,,,
Meridian Medicaid,DRG,484,"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,,,,,,,
Meridian Medicaid,DRG,491,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$5,943.01 ",IP,"5,943.01","5,943.01",,,,,,,,,,,,
Meridian Medicaid,DRG,492,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$9,716.03 ",IP,"9,716.03","9,716.03",,,,,,,,,,,,
Meridian Medicaid,DRG,493,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$11,066.13 ",IP,"11,066.13","11,066.13",,,,,,,,,,,,
Meridian Medicaid,DRG,494,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$20,732.33 ",IP,"20,732.33","20,732.33",,,,,,,,,,,,
Meridian Medicaid,DRG,501,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$3,211.53 ",IP,"3,211.53","3,211.53",,,,,,,,,,,,
Meridian Medicaid,DRG,502,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$6,688.34 ",IP,"6,688.34","6,688.34",,,,,,,,,,,,
Meridian Medicaid,DRG,503,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$10,165.49 ",IP,"10,165.49","10,165.49",,,,,,,,,,,,
Meridian Medicaid,DRG,504,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,,,,,,,
Meridian Medicaid,DRG,511,VIRAL MENINGITIS,,Relative Weights,"$2,048.35 ",IP,"2,048.35","2,048.35",,,,,,,,,,,,
Meridian Medicaid,DRG,512,VIRAL MENINGITIS,,Relative Weights,"$3,205.00 ",IP,"3,205.00","3,205.00",,,,,,,,,,,,
Meridian Medicaid,DRG,513,VIRAL MENINGITIS,,Relative Weights,"$5,993.52 ",IP,"5,993.52","5,993.52",,,,,,,,,,,,
Meridian Medicaid,DRG,514,VIRAL MENINGITIS,,Relative Weights,"$12,441.32 ",IP,"12,441.32","12,441.32",,,,,,,,,,,,
Meridian Medicaid,DRG,521,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,101.91 ",IP,"3,101.91","3,101.91",,,,,,,,,,,,
Meridian Medicaid,DRG,522,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,492.61 ",IP,"3,492.61","3,492.61",,,,,,,,,,,,
Meridian Medicaid,DRG,523,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$4,423.15 ",IP,"4,423.15","4,423.15",,,,,,,,,,,,
Meridian Medicaid,DRG,524,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$9,303.33 ",IP,"9,303.33","9,303.33",,,,,,,,,,,,
Meridian Medicaid,DRG,531,SEIZURE,,Relative Weights,"$2,710.87 ",IP,"2,710.87","2,710.87",,,,,,,,,,,,
Meridian Medicaid,DRG,532,SEIZURE,,Relative Weights,"$3,311.87 ",IP,"3,311.87","3,311.87",,,,,,,,,,,,
Meridian Medicaid,DRG,533,SEIZURE,,Relative Weights,"$4,410.44 ",IP,"4,410.44","4,410.44",,,,,,,,,,,,
Meridian Medicaid,DRG,534,SEIZURE,,Relative Weights,"$10,918.03 ",IP,"10,918.03","10,918.03",,,,,,,,,,,,
Meridian Medicaid,DRG,541,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$2,681.66 ",IP,"2,681.66","2,681.66",,,,,,,,,,,,
Meridian Medicaid,DRG,542,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,180.26 ",IP,"3,180.26","3,180.26",,,,,,,,,,,,
Meridian Medicaid,DRG,543,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,,,,,,,
Meridian Medicaid,DRG,544,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$6,681.46 ",IP,"6,681.46","6,681.46",,,,,,,,,,,,
Meridian Medicaid,DRG,551,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$3,376.47 ",IP,"3,376.47","3,376.47",,,,,,,,,,,,
Meridian Medicaid,DRG,552,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$4,570.57 ",IP,"4,570.57","4,570.57",,,,,,,,,,,,
Meridian Medicaid,DRG,553,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$6,561.54 ",IP,"6,561.54","6,561.54",,,,,,,,,,,,
Meridian Medicaid,DRG,554,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$13,008.65 ",IP,"13,008.65","13,008.65",,,,,,,,,,,,
Meridian Medicaid,DRG,561,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$3,264.10 ",IP,"3,264.10","3,264.10",,,,,,,,,,,,
Meridian Medicaid,DRG,562,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$4,370.58 ",IP,"4,370.58","4,370.58",,,,,,,,,,,,
Meridian Medicaid,DRG,563,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$6,249.87 ",IP,"6,249.87","6,249.87",,,,,,,,,,,,
Meridian Medicaid,DRG,564,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$13,974.93 ",IP,"13,974.93","13,974.93",,,,,,,,,,,,
Meridian Medicaid,DRG,571,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,,,,,,,
Meridian Medicaid,DRG,572,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$3,996.71 ",IP,"3,996.71","3,996.71",,,,,,,,,,,,
Meridian Medicaid,DRG,573,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$5,550.25 ",IP,"5,550.25","5,550.25",,,,,,,,,,,,
Meridian Medicaid,DRG,574,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$10,437.98 ",IP,"10,437.98","10,437.98",,,,,,,,,,,,
Meridian Medicaid,DRG,581,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$3,385.75 ",IP,"3,385.75","3,385.75",,,,,,,,,,,,
Meridian Medicaid,DRG,582,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$4,062.35 ",IP,"4,062.35","4,062.35",,,,,,,,,,,,
Meridian Medicaid,DRG,583,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$5,313.15 ",IP,"5,313.15","5,313.15",,,,,,,,,,,,
Meridian Medicaid,DRG,584,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$10,386.78 ",IP,"10,386.78","10,386.78",,,,,,,,,,,,
Meridian Medicaid,DRG,591,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$3,746.90 ",IP,"3,746.90","3,746.90",,,,,,,,,,,,
Meridian Medicaid,DRG,592,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$4,463.01 ",IP,"4,463.01","4,463.01",,,,,,,,,,,,
Meridian Medicaid,DRG,593,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$6,809.98 ",IP,"6,809.98","6,809.98",,,,,,,,,,,,
Meridian Medicaid,DRG,594,ANOXIC & OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$11,699.43 ",IP,"11,699.43","11,699.43",,,,,,,,,,,,
Meridian Medicaid,DRG,731,ORBIT AND EYE PROCEDURES,,Relative Weights,"$5,014.53 ",IP,"5,014.53","5,014.53",,,,,,,,,,,,
Meridian Medicaid,DRG,732,ORBIT AND EYE PROCEDURES,,Relative Weights,"$6,421.34 ",IP,"6,421.34","6,421.34",,,,,,,,,,,,
Meridian Medicaid,DRG,733,ORBIT AND EYE PROCEDURES,,Relative Weights,"$9,718.43 ",IP,"9,718.43","9,718.43",,,,,,,,,,,,
Meridian Medicaid,DRG,734,ORBIT AND EYE PROCEDURES,,Relative Weights,"$22,403.73 ",IP,"22,403.73","22,403.73",,,,,,,,,,,,
Meridian Medicaid,DRG,821,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$2,633.21 ",IP,"2,633.21","2,633.21",,,,,,,,,,,,
Meridian Medicaid,DRG,822,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$3,410.83 ",IP,"3,410.83","3,410.83",,,,,,,,,,,,
Meridian Medicaid,DRG,823,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$4,809.73 ",IP,"4,809.73","4,809.73",,,,,,,,,,,,
Meridian Medicaid,DRG,824,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$13,027.89 ",IP,"13,027.89","13,027.89",,,,,,,,,,,,
Meridian Medicaid,DRG,891,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$9,059.01 ",IP,"9,059.01","9,059.01",,,,,,,,,,,,
Meridian Medicaid,DRG,892,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$11,457.52 ",IP,"11,457.52","11,457.52",,,,,,,,,,,,
Meridian Medicaid,DRG,893,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$17,804.98 ",IP,"17,804.98","17,804.98",,,,,,,,,,,,
Meridian Medicaid,DRG,894,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$32,041.75 ",IP,"32,041.75","32,041.75",,,,,,,,,,,,
Meridian Medicaid,DRG,911,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$6,729.57 ",IP,"6,729.57","6,729.57",,,,,,,,,,,,
Meridian Medicaid,DRG,912,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$9,964.47 ",IP,"9,964.47","9,964.47",,,,,,,,,,,,
Meridian Medicaid,DRG,913,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$16,613.29 ",IP,"16,613.29","16,613.29",,,,,,,,,,,,
Meridian Medicaid,DRG,914,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$32,825.56 ",IP,"32,825.56","32,825.56",,,,,,,,,,,,
Meridian Medicaid,DRG,921,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$6,039.23 ",IP,"6,039.23","6,039.23",,,,,,,,,,,,
Meridian Medicaid,DRG,922,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$8,191.36 ",IP,"8,191.36","8,191.36",,,,,,,,,,,,
Meridian Medicaid,DRG,923,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$13,246.44 ",IP,"13,246.44","13,246.44",,,,,,,,,,,,
Meridian Medicaid,DRG,924,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$30,839.40 ",IP,"30,839.40","30,839.40",,,,,,,,,,,,
Meridian Medicaid,DRG,951,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,246.53 ",IP,"4,246.53","4,246.53",,,,,,,,,,,,
Meridian Medicaid,DRG,952,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,,,,,,,
Meridian Medicaid,DRG,953,CLEFT LIP & PALATE REPAIR,,Relative Weights,"$7,436.75 ",IP,"7,436.75","7,436.75",,,,,,,,,,,,
Meridian Medicaid,DRG,954,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$14,987.25 ",IP,"14,987.25","14,987.25",,,,,,,,,,,,
Meridian Medicaid,DRG,971,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$2,853.47 ",IP,"2,853.47","2,853.47",,,,,,,,,,,,
Meridian Medicaid,DRG,972,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$3,981.59 ",IP,"3,981.59","3,981.59",,,,,,,,,,,,
Meridian Medicaid,DRG,973,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$6,406.56 ",IP,"6,406.56","6,406.56",,,,,,,,,,,,
Meridian Medicaid,DRG,974,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$15,100.30 ",IP,"15,100.30","15,100.30",,,,,,,,,,,,
Meridian Medicaid,DRG,981,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$4,806.30 ",IP,"4,806.30","4,806.30",,,,,,,,,,,,
Meridian Medicaid,DRG,982,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$6,289.73 ",IP,"6,289.73","6,289.73",,,,,,,,,,,,
Meridian Medicaid,DRG,983,"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",,Relative Weights,"$10,153.46 ",IP,"10,153.46","10,153.46",,,,,,,,,,,,
Meridian Medicaid,DRG,984,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$19,630.32 ",IP,"19,630.32","19,630.32",,,,,,,,,,,,
Meridian Medicaid,DRG,1101,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,539.30 ",IP,"4,539.30","4,539.30",,,,,,,,,,,,
Meridian Medicaid,DRG,1102,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,571.26 ",IP,"4,571.26","4,571.26",,,,,,,,,,,,
Meridian Medicaid,DRG,1103,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$6,424.43 ",IP,"6,424.43","6,424.43",,,,,,,,,,,,
Meridian Medicaid,DRG,1104,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$10,388.84 ",IP,"10,388.84","10,388.84",,,,,,,,,,,,
Meridian Medicaid,DRG,1111,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,014.97 ",IP,"3,014.97","3,014.97",,,,,,,,,,,,
Meridian Medicaid,DRG,1112,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,232.83 ",IP,"3,232.83","3,232.83",,,,,,,,,,,,
Meridian Medicaid,DRG,1113,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,830.06 ",IP,"3,830.06","3,830.06",,,,,,,,,,,,
Meridian Medicaid,DRG,1114,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$5,856.07 ",IP,"5,856.07","5,856.07",,,,,,,,,,,,
Meridian Medicaid,DRG,1131,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$1,710.57 ",IP,"1,710.57","1,710.57",,,,,,,,,,,,
Meridian Medicaid,DRG,1132,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$2,449.71 ",IP,"2,449.71","2,449.71",,,,,,,,,,,,
Meridian Medicaid,DRG,1133,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$3,709.10 ",IP,"3,709.10","3,709.10",,,,,,,,,,,,
Meridian Medicaid,DRG,1134,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$7,363.91 ",IP,"7,363.91","7,363.91",,,,,,,,,,,,
Meridian Medicaid,DRG,1141,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$2,233.23 ",IP,"2,233.23","2,233.23",,,,,,,,,,,,
Meridian Medicaid,DRG,1142,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$3,024.94 ",IP,"3,024.94","3,024.94",,,,,,,,,,,,
Meridian Medicaid,DRG,1143,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$4,392.57 ",IP,"4,392.57","4,392.57",,,,,,,,,,,,
Meridian Medicaid,DRG,1144,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$11,476.08 ",IP,"11,476.08","11,476.08",,,,,,,,,,,,
Meridian Medicaid,DRG,1151,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$2,472.39 ",IP,"2,472.39","2,472.39",,,,,,,,,,,,
Meridian Medicaid,DRG,1152,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$3,380.25 ",IP,"3,380.25","3,380.25",,,,,,,,,,,,
Meridian Medicaid,DRG,1153,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$4,829.66 ",IP,"4,829.66","4,829.66",,,,,,,,,,,,
Meridian Medicaid,DRG,1154,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$10,560.66 ",IP,"10,560.66","10,560.66",,,,,,,,,,,,
Meridian Medicaid,DRG,1201,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,978.60 ",IP,"8,978.60","8,978.60",,,,,,,,,,,,
Meridian Medicaid,DRG,1202,MAJOR RESPIRATORY & CHEST PROCEDURES,,Relative Weights,"$10,724.22 ",IP,"10,724.22","10,724.22",,,,,,,,,,,,
Meridian Medicaid,DRG,1203,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$15,096.86 ",IP,"15,096.86","15,096.86",,,,,,,,,,,,
Meridian Medicaid,DRG,1204,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$30,187.20 ",IP,"30,187.20","30,187.20",,,,,,,,,,,,
Meridian Medicaid,DRG,1211,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$6,647.79 ",IP,"6,647.79","6,647.79",,,,,,,,,,,,
Meridian Medicaid,DRG,1212,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,066.62 ",IP,"8,066.62","8,066.62",,,,,,,,,,,,
Meridian Medicaid,DRG,1213,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$12,267.10 ",IP,"12,267.10","12,267.10",,,,,,,,,,,,
Meridian Medicaid,DRG,1214,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$23,708.13 ",IP,"23,708.13","23,708.13",,,,,,,,,,,,
Meridian Medicaid,DRG,1301,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$15,152.88 ",IP,"15,152.88","15,152.88",,,,,,,,,,,,
Meridian Medicaid,DRG,1302,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,,Relative Weights,"$17,209.82 ",IP,"17,209.82","17,209.82",,,,,,,,,,,,
Meridian Medicaid,DRG,1303,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$20,315.17 ",IP,"20,315.17","20,315.17",,,,,,,,,,,,
Meridian Medicaid,DRG,1304,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$28,326.47 ",IP,"28,326.47","28,326.47",,,,,,,,,,,,
Meridian Medicaid,DRG,1311,CYSTIC FIBROSIS PULMONARY DISEASE,,Relative Weights,"$6,540.23 ",IP,"6,540.23","6,540.23",,,,,,,,,,,,
Meridian Medicaid,DRG,1312,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$9,797.46 ",IP,"9,797.46","9,797.46",,,,,,,,,,,,
Meridian Medicaid,DRG,1313,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$13,253.65 ",IP,"13,253.65","13,253.65",,,,,,,,,,,,
Meridian Medicaid,DRG,1314,CYSTIC FIBROSIS PULMONARY DISEASE,,Relative Weights,"$17,241.78 ",IP,"17,241.78","17,241.78",,,,,,,,,,,,
Meridian Medicaid,DRG,1321,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$2,377.20 ",IP,"2,377.20","2,377.20",,,,,,,,,,,,
Meridian Medicaid,DRG,1322,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$3,157.24 ",IP,"3,157.24","3,157.24",,,,,,,,,,,,
Meridian Medicaid,DRG,1323,BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$5,204.90 ",IP,"5,204.90","5,204.90",,,,,,,,,,,,
Meridian Medicaid,DRG,1324,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$9,706.75 ",IP,"9,706.75","9,706.75",,,,,,,,,,,,
Meridian Medicaid,DRG,1331,RESPIRATORY FAILURE,,Relative Weights,"$2,072.41 ",IP,"2,072.41","2,072.41",,,,,,,,,,,,
Meridian Medicaid,DRG,1332,RESPIRATORY FAILURE,,Relative Weights,"$3,703.26 ",IP,"3,703.26","3,703.26",,,,,,,,,,,,
Meridian Medicaid,DRG,1333,RESPIRATORY FAILURE,,Relative Weights,"$5,064.70 ",IP,"5,064.70","5,064.70",,,,,,,,,,,,
Meridian Medicaid,DRG,1334,RESPIRATORY FAILURE,,Relative Weights,"$9,349.38 ",IP,"9,349.38","9,349.38",,,,,,,,,,,,
Meridian Medicaid,DRG,1341,PULMONARY EMBOLISM,,Relative Weights,"$2,977.18 ",IP,"2,977.18","2,977.18",,,,,,,,,,,,
Meridian Medicaid,DRG,1342,PULMONARY EMBOLISM,,Relative Weights,"$3,832.12 ",IP,"3,832.12","3,832.12",,,,,,,,,,,,
Meridian Medicaid,DRG,1343,PULMONARY EMBOLISM,,Relative Weights,"$5,276.03 ",IP,"5,276.03","5,276.03",,,,,,,,,,,,
Meridian Medicaid,DRG,1344,PULMONARY EMBOLISM,,Relative Weights,"$8,166.27 ",IP,"8,166.27","8,166.27",,,,,,,,,,,,
Meridian Medicaid,DRG,1351,MAJOR CHEST and RESPIRAZORY TRAUMA,,Relative Weights,"$3,792.26 ",IP,"3,792.26","3,792.26",,,,,,,,,,,,
Meridian Medicaid,DRG,1352,MAJOR CHEST & RESPIRATORY TRAUMA,,Relative Weights,"$3,955.48 ",IP,"3,955.48","3,955.48",,,,,,,,,,,,
Meridian Medicaid,DRG,1353,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$5,683.92 ",IP,"5,683.92","5,683.92",,,,,,,,,,,,
Meridian Medicaid,DRG,1354,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$10,178.89 ",IP,"10,178.89","10,178.89",,,,,,,,,,,,
Meridian Medicaid,DRG,1361,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,244.47 ",IP,"4,244.47","4,244.47",,,,,,,,,,,,
Meridian Medicaid,DRG,1362,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,742.73 ",IP,"4,742.73","4,742.73",,,,,,,,,,,,
Meridian Medicaid,DRG,1363,RESPIRATORY MALIGNANCY,,Relative Weights,"$6,049.19 ",IP,"6,049.19","6,049.19",,,,,,,,,,,,
Meridian Medicaid,DRG,1364,RESPIRATORY MALIGNANCY,,Relative Weights,"$9,049.05 ",IP,"9,049.05","9,049.05",,,,,,,,,,,,
Meridian Medicaid,DRG,1371,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,151.74 ",IP,"3,151.74","3,151.74",,,,,,,,,,,,
Meridian Medicaid,DRG,1372,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,930.39 ",IP,"3,930.39","3,930.39",,,,,,,,,,,,
Meridian Medicaid,DRG,1373,MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,,Relative Weights,"$5,471.90 ",IP,"5,471.90","5,471.90",,,,,,,,,,,,
Meridian Medicaid,DRG,1374,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$8,758.68 ",IP,"8,758.68","8,758.68",,,,,,,,,,,,
Meridian Medicaid,DRG,1381,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$1,796.82 ",IP,"1,796.82","1,796.82",,,,,,,,,,,,
Meridian Medicaid,DRG,1382,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$2,575.82 ",IP,"2,575.82","2,575.82",,,,,,,,,,,,
Meridian Medicaid,DRG,1383,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$4,712.83 ",IP,"4,712.83","4,712.83",,,,,,,,,,,,
Meridian Medicaid,DRG,1384,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$9,865.85 ",IP,"9,865.85","9,865.85",,,,,,,,,,,,
Meridian Medicaid,DRG,1391,OTHER PNEUMONIA,,Relative Weights,"$2,182.71 ",IP,"2,182.71","2,182.71",,,,,,,,,,,,
Meridian Medicaid,DRG,1392,OTHER PNEUMONIA,,Relative Weights,"$3,016.35 ",IP,"3,016.35","3,016.35",,,,,,,,,,,,
Meridian Medicaid,DRG,1393,OTHER PNEUMONIA,,Relative Weights,"$4,342.75 ",IP,"4,342.75","4,342.75",,,,,,,,,,,,
Meridian Medicaid,DRG,1394,OTHER PNEUMONIA,,Relative Weights,"$7,186.59 ",IP,"7,186.59","7,186.59",,,,,,,,,,,,
Meridian Medicaid,DRG,1401,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$2,639.05 ",IP,"2,639.05","2,639.05",,,,,,,,,,,,
Meridian Medicaid,DRG,1402,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,167.20 ",IP,"3,167.20","3,167.20",,,,,,,,,,,,
Meridian Medicaid,DRG,1403,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,958.92 ",IP,"3,958.92","3,958.92",,,,,,,,,,,,
Meridian Medicaid,DRG,1404,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$5,969.47 ",IP,"5,969.47","5,969.47",,,,,,,,,,,,
Meridian Medicaid,DRG,1411,ASTHMA,,Relative Weights,"$2,018.80 ",IP,"2,018.80","2,018.80",,,,,,,,,,,,
Meridian Medicaid,DRG,1412,ASTHMA,,Relative Weights,"$2,763.78 ",IP,"2,763.78","2,763.78",,,,,,,,,,,,
Meridian Medicaid,DRG,1413,ASTHMA,,Relative Weights,"$4,049.98 ",IP,"4,049.98","4,049.98",,,,,,,,,,,,
Meridian Medicaid,DRG,1414,ASTHMA,,Relative Weights,"$6,508.28 ",IP,"6,508.28","6,508.28",,,,,,,,,,,,
Meridian Medicaid,DRG,1421,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,358.26 ",IP,"3,358.26","3,358.26",,,,,,,,,,,,
Meridian Medicaid,DRG,1422,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,679.89 ",IP,"3,679.89","3,679.89",,,,,,,,,,,,
Meridian Medicaid,DRG,1423,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$4,888.08 ",IP,"4,888.08","4,888.08",,,,,,,,,,,,
Meridian Medicaid,DRG,1424,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$7,901.68 ",IP,"7,901.68","7,901.68",,,,,,,,,,,,
Meridian Medicaid,DRG,1431,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$2,504.69 ",IP,"2,504.69","2,504.69",,,,,,,,,,,,
Meridian Medicaid,DRG,1432,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,509.11 ",IP,"3,509.11","3,509.11",,,,,,,,,,,,
Meridian Medicaid,DRG,1433,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$5,145.11 ",IP,"5,145.11","5,145.11",,,,,,,,,,,,
Meridian Medicaid,DRG,1434,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$8,358.70 ",IP,"8,358.70","8,358.70",,,,,,,,,,,,
Meridian Medicaid,DRG,1441,"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",,Relative Weights,"$2,636.99 ",IP,"2,636.99","2,636.99",,,,,,,,,,,,
Meridian Medicaid,DRG,1442,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,405.68 ",IP,"3,405.68","3,405.68",,,,,,,,,,,,
Meridian Medicaid,DRG,1443,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$4,454.42 ",IP,"4,454.42","4,454.42",,,,,,,,,,,,
Meridian Medicaid,DRG,1444,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$7,998.24 ",IP,"7,998.24","7,998.24",,,,,,,,,,,,
Meridian Medicaid,DRG,1451,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,478.23 ",IP,"2,478.23","2,478.23",,,,,,,,,,,,
Meridian Medicaid,DRG,1452,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,974.43 ",IP,"2,974.43","2,974.43",,,,,,,,,,,,
Meridian Medicaid,DRG,1453,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$3,820.09 ",IP,"3,820.09","3,820.09",,,,,,,,,,,,
Meridian Medicaid,DRG,1454,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$6,746.07 ",IP,"6,746.07","6,746.07",,,,,,,,,,,,
Meridian Medicaid,DRG,1601,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$19,007.33 ",IP,"19,007.33","19,007.33",,,,,,,,,,,,
Meridian Medicaid,DRG,1602,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$21,418.55 ",IP,"21,418.55","21,418.55",,,,,,,,,,,,
Meridian Medicaid,DRG,1603,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$29,897.52 ",IP,"29,897.52","29,897.52",,,,,,,,,,,,
Meridian Medicaid,DRG,1604,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$58,616.75 ",IP,"58,616.75","58,616.75",,,,,,,,,,,,
Meridian Medicaid,DRG,1611,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$21,623.70 ",IP,"21,623.70","21,623.70",,,,,,,,,,,,
Meridian Medicaid,DRG,1612,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$25,324.21 ",IP,"25,324.21","25,324.21",,,,,,,,,,,,
Meridian Medicaid,DRG,1613,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$37,168.99 ",IP,"37,168.99","37,168.99",,,,,,,,,,,,
Meridian Medicaid,DRG,1614,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$84,952.59 ",IP,"84,952.59","84,952.59",,,,,,,,,,,,
Meridian Medicaid,DRG,1621,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$21,734.00 ",IP,"21,734.00","21,734.00",,,,,,,,,,,,
Meridian Medicaid,DRG,1622,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$25,647.21 ",IP,"25,647.21","25,647.21",,,,,,,,,,,,
Meridian Medicaid,DRG,1623,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$32,557.19 ",IP,"32,557.19","32,557.19",,,,,,,,,,,,
Meridian Medicaid,DRG,1624,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$51,493.39 ",IP,"51,493.39","51,493.39",,,,,,,,,,,,
Meridian Medicaid,DRG,1631,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$18,870.57 ",IP,"18,870.57","18,870.57",,,,,,,,,,,,
Meridian Medicaid,DRG,1632,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$20,678.38 ",IP,"20,678.38","20,678.38",,,,,,,,,,,,
Meridian Medicaid,DRG,1633,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$25,441.73 ",IP,"25,441.73","25,441.73",,,,,,,,,,,,
Meridian Medicaid,DRG,1634,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$42,290.40 ",IP,"42,290.40","42,290.40",,,,,,,,,,,,
Meridian Medicaid,DRG,1651,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$17,424.93 ",IP,"17,424.93","17,424.93",,,,,,,,,,,,
Meridian Medicaid,DRG,1652,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$20,592.13 ",IP,"20,592.13","20,592.13",,,,,,,,,,,,
Meridian Medicaid,DRG,1653,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$24,876.46 ",IP,"24,876.46","24,876.46",,,,,,,,,,,,
Meridian Medicaid,DRG,1654,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$37,414.00 ",IP,"37,414.00","37,414.00",,,,,,,,,,,,
Meridian Medicaid,DRG,1661,CORONARY BYPASS W/O AMI OR COMPLEX PDX,,Relative Weights,"$16,087.19 ",IP,"16,087.19","16,087.19",,,,,,,,,,,,
Meridian Medicaid,DRG,1662,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$17,173.40 ",IP,"17,173.40","17,173.40",,,,,,,,,,,,
Meridian Medicaid,DRG,1663,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$20,743.67 ",IP,"20,743.67","20,743.67",,,,,,,,,,,,
Meridian Medicaid,DRG,1664,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$33,503.88 ",IP,"33,503.88","33,503.88",,,,,,,,,,,,
Meridian Medicaid,DRG,1671,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$15,753.88 ",IP,"15,753.88","15,753.88",,,,,,,,,,,,
Meridian Medicaid,DRG,1672,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$16,654.52 ",IP,"16,654.52","16,654.52",,,,,,,,,,,,
Meridian Medicaid,DRG,1673,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$20,943.66 ",IP,"20,943.66","20,943.66",,,,,,,,,,,,
Meridian Medicaid,DRG,1674,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$39,564.41 ",IP,"39,564.41","39,564.41",,,,,,,,,,,,
Meridian Medicaid,DRG,1691,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$9,314.67 ",IP,"9,314.67","9,314.67",,,,,,,,,,,,
Meridian Medicaid,DRG,1692,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$12,244.08 ",IP,"12,244.08","12,244.08",,,,,,,,,,,,
Meridian Medicaid,DRG,1693,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$19,456.45 ",IP,"19,456.45","19,456.45",,,,,,,,,,,,
Meridian Medicaid,DRG,1694,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$33,906.95 ",IP,"33,906.95","33,906.95",,,,,,,,,,,,
Meridian Medicaid,DRG,1701,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,265.14 ",IP,"10,265.14","10,265.14",,,,,,,,,,,,
Meridian Medicaid,DRG,1702,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,949.99 ",IP,"10,949.99","10,949.99",,,,,,,,,,,,
Meridian Medicaid,DRG,1703,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$13,975.61 ",IP,"13,975.61","13,975.61",,,,,,,,,,,,
Meridian Medicaid,DRG,1704,"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",,Relative Weights,"$19,895.26 ",IP,"19,895.26","19,895.26",,,,,,,,,,,,
Meridian Medicaid,DRG,1711,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$8,272.45 ",IP,"8,272.45","8,272.45",,,,,,,,,,,,
Meridian Medicaid,DRG,1712,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$9,180.66 ",IP,"9,180.66","9,180.66",,,,,,,,,,,,
Meridian Medicaid,DRG,1713,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,971.29 ",IP,"10,971.29","10,971.29",,,,,,,,,,,,
Meridian Medicaid,DRG,1714,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$17,965.80 ",IP,"17,965.80","17,965.80",,,,,,,,,,,,
Meridian Medicaid,DRG,1741,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$9,597.47 ",IP,"9,597.47","9,597.47",,,,,,,,,,,,
Meridian Medicaid,DRG,1742,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$10,364.10 ",IP,"10,364.10","10,364.10",,,,,,,,,,,,
Meridian Medicaid,DRG,1743,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$12,874.29 ",IP,"12,874.29","12,874.29",,,,,,,,,,,,
Meridian Medicaid,DRG,1744,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$19,364.01 ",IP,"19,364.01","19,364.01",,,,,,,,,,,,
Meridian Medicaid,DRG,1751,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$11,256.84 ",IP,"11,256.84","11,256.84",,,,,,,,,,,,
Meridian Medicaid,DRG,1752,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$12,009.39 ",IP,"12,009.39","12,009.39",,,,,,,,,,,,
Meridian Medicaid,DRG,1753,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$14,253.95 ",IP,"14,253.95","14,253.95",,,,,,,,,,,,
Meridian Medicaid,DRG,1754,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$25,147.58 ",IP,"25,147.58","25,147.58",,,,,,,,,,,,
Meridian Medicaid,DRG,1761,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$9,268.97 ",IP,"9,268.97","9,268.97",,,,,,,,,,,,
Meridian Medicaid,DRG,1762,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$10,537.63 ",IP,"10,537.63","10,537.63",,,,,,,,,,,,
Meridian Medicaid,DRG,1763,CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$15,961.08 ",IP,"15,961.08","15,961.08",,,,,,,,,,,,
Meridian Medicaid,DRG,1764,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$25,961.29 ",IP,"25,961.29","25,961.29",,,,,,,,,,,,
Meridian Medicaid,DRG,1771,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$6,530.96 ",IP,"6,530.96","6,530.96",,,,,,,,,,,,
Meridian Medicaid,DRG,1772,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$9,029.80 ",IP,"9,029.80","9,029.80",,,,,,,,,,,,
Meridian Medicaid,DRG,1773,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$11,280.21 ",IP,"11,280.21","11,280.21",,,,,,,,,,,,
Meridian Medicaid,DRG,1774,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$17,033.20 ",IP,"17,033.20","17,033.20",,,,,,,,,,,,
Meridian Medicaid,DRG,1801,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$6,351.58 ",IP,"6,351.58","6,351.58",,,,,,,,,,,,
Meridian Medicaid,DRG,1802,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$7,715.78 ",IP,"7,715.78","7,715.78",,,,,,,,,,,,
Meridian Medicaid,DRG,1803,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$10,872.33 ",IP,"10,872.33","10,872.33",,,,,,,,,,,,
Meridian Medicaid,DRG,1804,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$20,062.95 ",IP,"20,062.95","20,062.95",,,,,,,,,,,,
Meridian Medicaid,DRG,1811,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$9,268.28 ",IP,"9,268.28","9,268.28",,,,,,,,,,,,
Meridian Medicaid,DRG,1812,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$11,438.97 ",IP,"11,438.97","11,438.97",,,,,,,,,,,,
Meridian Medicaid,DRG,1813,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$16,303.68 ",IP,"16,303.68","16,303.68",,,,,,,,,,,,
Meridian Medicaid,DRG,1814,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$27,105.22 ",IP,"27,105.22","27,105.22",,,,,,,,,,,,
Meridian Medicaid,DRG,1821,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$9,585.79 ",IP,"9,585.79","9,585.79",,,,,,,,,,,,
Meridian Medicaid,DRG,1822,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$11,451.68 ",IP,"11,451.68","11,451.68",,,,,,,,,,,,
Meridian Medicaid,DRG,1823,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$12,966.73 ",IP,"12,966.73","12,966.73",,,,,,,,,,,,
Meridian Medicaid,DRG,1824,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$25,526.94 ",IP,"25,526.94","25,526.94",,,,,,,,,,,,
Meridian Medicaid,DRG,1901,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$3,454.82 ",IP,"3,454.82","3,454.82",,,,,,,,,,,,
Meridian Medicaid,DRG,1902,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$4,023.17 ",IP,"4,023.17","4,023.17",,,,,,,,,,,,
Meridian Medicaid,DRG,1903,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$5,278.78 ",IP,"5,278.78","5,278.78",,,,,,,,,,,,
Meridian Medicaid,DRG,1904,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$8,568.66 ",IP,"8,568.66","8,568.66",,,,,,,,,,,,
Meridian Medicaid,DRG,1911,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$4,795.99 ",IP,"4,795.99","4,795.99",,,,,,,,,,,,
Meridian Medicaid,DRG,1912,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$5,349.23 ",IP,"5,349.23","5,349.23",,,,,,,,,,,,
Meridian Medicaid,DRG,1913,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$6,652.26 ",IP,"6,652.26","6,652.26",,,,,,,,,,,,
Meridian Medicaid,DRG,1914,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$10,568.22 ",IP,"10,568.22","10,568.22",,,,,,,,,,,,
Meridian Medicaid,DRG,1921,CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,,Relative Weights,"$5,126.56 ",IP,"5,126.56","5,126.56",,,,,,,,,,,,
Meridian Medicaid,DRG,1922,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$5,995.59 ",IP,"5,995.59","5,995.59",,,,,,,,,,,,
Meridian Medicaid,DRG,1923,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$8,192.04 ",IP,"8,192.04","8,192.04",,,,,,,,,,,,
Meridian Medicaid,DRG,1924,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$14,030.25 ",IP,"14,030.25","14,030.25",,,,,,,,,,,,
Meridian Medicaid,DRG,1931,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$4,156.16 ",IP,"4,156.16","4,156.16",,,,,,,,,,,,
Meridian Medicaid,DRG,1932,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$5,201.81 ",IP,"5,201.81","5,201.81",,,,,,,,,,,,
Meridian Medicaid,DRG,1933,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$7,472.15 ",IP,"7,472.15","7,472.15",,,,,,,,,,,,
Meridian Medicaid,DRG,1934,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$12,655.75 ",IP,"12,655.75","12,655.75",,,,,,,,,,,,
Meridian Medicaid,DRG,1941,HEART FAILURE,,Relative Weights,"$2,590.60 ",IP,"2,590.60","2,590.60",,,,,,,,,,,,
Meridian Medicaid,DRG,1942,HEART FAILURE,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,,,,,,,
Meridian Medicaid,DRG,1943,HEART FAILURE,,Relative Weights,"$4,368.86 ",IP,"4,368.86","4,368.86",,,,,,,,,,,,
Meridian Medicaid,DRG,1944,HEART FAILURE,,Relative Weights,"$7,070.79 ",IP,"7,070.79","7,070.79",,,,,,,,,,,,
Meridian Medicaid,DRG,1961,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,365.52 ",IP,"2,365.52","2,365.52",,,,,,,,,,,,
Meridian Medicaid,DRG,1962,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,596.44 ",IP,"2,596.44","2,596.44",,,,,,,,,,,,
Meridian Medicaid,DRG,1963,CARDIAC ARREST & SHOCK,,Relative Weights,"$4,010.12 ",IP,"4,010.12","4,010.12",,,,,,,,,,,,
Meridian Medicaid,DRG,1964,CARDIAC ARREST & SHOCK,,Relative Weights,"$8,325.03 ",IP,"8,325.03","8,325.03",,,,,,,,,,,,
Meridian Medicaid,DRG,1971,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$2,758.63 ",IP,"2,758.63","2,758.63",,,,,,,,,,,,
Meridian Medicaid,DRG,1972,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$3,488.49 ",IP,"3,488.49","3,488.49",,,,,,,,,,,,
Meridian Medicaid,DRG,1973,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$4,794.61 ",IP,"4,794.61","4,794.61",,,,,,,,,,,,
Meridian Medicaid,DRG,1974,PERIPHERAL & OTHER VASCULAR DISORDERS,,Relative Weights,"$9,053.51 ",IP,"9,053.51","9,053.51",,,,,,,,,,,,
Meridian Medicaid,DRG,1981,ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,680.28 ",IP,"2,680.28","2,680.28",,,,,,,,,,,,
Meridian Medicaid,DRG,1982,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,985.77 ",IP,"2,985.77","2,985.77",,,,,,,,,,,,
Meridian Medicaid,DRG,1983,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$3,628.00 ",IP,"3,628.00","3,628.00",,,,,,,,,,,,
Meridian Medicaid,DRG,1984,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$6,763.25 ",IP,"6,763.25","6,763.25",,,,,,,,,,,,
Meridian Medicaid,DRG,1991,HYPERTENSION,,Relative Weights,"$2,662.41 ",IP,"2,662.41","2,662.41",,,,,,,,,,,,
Meridian Medicaid,DRG,1992,HYPERTENSION,,Relative Weights,"$2,956.56 ",IP,"2,956.56","2,956.56",,,,,,,,,,,,
Meridian Medicaid,DRG,1993,HYPERTENSION,,Relative Weights,"$3,736.93 ",IP,"3,736.93","3,736.93",,,,,,,,,,,,
Meridian Medicaid,DRG,1994,HYPERTENSION,,Relative Weights,"$6,634.39 ",IP,"6,634.39","6,634.39",,,,,,,,,,,,
Meridian Medicaid,DRG,2001,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$2,919.45 ",IP,"2,919.45","2,919.45",,,,,,,,,,,,
Meridian Medicaid,DRG,2002,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$3,565.12 ",IP,"3,565.12","3,565.12",,,,,,,,,,,,
Meridian Medicaid,DRG,2003,CARDIAC STRUCTURAL & VALVULAR DISORDERS,,Relative Weights,"$4,853.03 ",IP,"4,853.03","4,853.03",,,,,,,,,,,,
Meridian Medicaid,DRG,2004,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$10,524.92 ",IP,"10,524.92","10,524.92",,,,,,,,,,,,
Meridian Medicaid,DRG,2011,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,322.91 ",IP,"2,322.91","2,322.91",,,,,,,,,,,,
Meridian Medicaid,DRG,2012,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,865.50 ",IP,"2,865.50","2,865.50",,,,,,,,,,,,
Meridian Medicaid,DRG,2013,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$3,988.81 ",IP,"3,988.81","3,988.81",,,,,,,,,,,,
Meridian Medicaid,DRG,2014,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$7,490.70 ",IP,"7,490.70","7,490.70",,,,,,,,,,,,
Meridian Medicaid,DRG,2031,CHEST PAIN,,Relative Weights,"$2,896.08 ",IP,"2,896.08","2,896.08",,,,,,,,,,,,
Meridian Medicaid,DRG,2032,CHEST PAIN,,Relative Weights,"$3,156.55 ",IP,"3,156.55","3,156.55",,,,,,,,,,,,
Meridian Medicaid,DRG,2033,CHEST PAIN,,Relative Weights,"$3,647.25 ",IP,"3,647.25","3,647.25",,,,,,,,,,,,
Meridian Medicaid,DRG,2034,CHEST PAIN,,Relative Weights,"$5,656.08 ",IP,"5,656.08","5,656.08",,,,,,,,,,,,
Meridian Medicaid,DRG,2041,SYNCOPE and COLLAPSE,,Relative Weights,"$3,210.15 ",IP,"3,210.15","3,210.15",,,,,,,,,,,,
Meridian Medicaid,DRG,2042,SYNCOPE and COLLAPSE,,Relative Weights,"$3,469.25 ",IP,"3,469.25","3,469.25",,,,,,,,,,,,
Meridian Medicaid,DRG,2043,SYNCOPE and COLLAPSE,,Relative Weights,"$3,913.56 ",IP,"3,913.56","3,913.56",,,,,,,,,,,,
Meridian Medicaid,DRG,2044,SYNCOPE and COLLAPSE,,Relative Weights,"$6,621.67 ",IP,"6,621.67","6,621.67",,,,,,,,,,,,
Meridian Medicaid,DRG,2051,CARDIOMYOPATHY,,Relative Weights,"$3,094.70 ",IP,"3,094.70","3,094.70",,,,,,,,,,,,
Meridian Medicaid,DRG,2052,CARDIOMYOPATHY,,Relative Weights,"$3,108.78 ",IP,"3,108.78","3,108.78",,,,,,,,,,,,
Meridian Medicaid,DRG,2053,CARDIOMYOPATHY,,Relative Weights,"$4,834.47 ",IP,"4,834.47","4,834.47",,,,,,,,,,,,
Meridian Medicaid,DRG,2054,CARDIOMYOPATHY,,Relative Weights,"$12,099.76 ",IP,"12,099.76","12,099.76",,,,,,,,,,,,
Meridian Medicaid,DRG,2061,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$3,915.62 ",IP,"3,915.62","3,915.62",,,,,,,,,,,,
Meridian Medicaid,DRG,2062,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$4,064.41 ",IP,"4,064.41","4,064.41",,,,,,,,,,,,
Meridian Medicaid,DRG,2063,"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",,Relative Weights,"$5,616.22 ",IP,"5,616.22","5,616.22",,,,,,,,,,,,
Meridian Medicaid,DRG,2064,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$11,629.68 ",IP,"11,629.68","11,629.68",,,,,,,,,,,,
Meridian Medicaid,DRG,2071,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$2,947.97 ",IP,"2,947.97","2,947.97",,,,,,,,,,,,
Meridian Medicaid,DRG,2072,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$3,511.17 ",IP,"3,511.17","3,511.17",,,,,,,,,,,,
Meridian Medicaid,DRG,2073,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$4,590.50 ",IP,"4,590.50","4,590.50",,,,,,,,,,,,
Meridian Medicaid,DRG,2074,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$8,837.72 ",IP,"8,837.72","8,837.72",,,,,,,,,,,,
Meridian Medicaid,DRG,2201,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$7,004.47 ",IP,"7,004.47","7,004.47",,,,,,,,,,,,
Meridian Medicaid,DRG,2202,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$10,124.94 ",IP,"10,124.94","10,124.94",,,,,,,,,,,,
Meridian Medicaid,DRG,2203,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$15,446.33 ",IP,"15,446.33","15,446.33",,,,,,,,,,,,
Meridian Medicaid,DRG,2204,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$29,728.80 ",IP,"29,728.80","29,728.80",,,,,,,,,,,,
Meridian Medicaid,DRG,2221,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$3,629.38 ",IP,"3,629.38","3,629.38",,,,,,,,,,,,
Meridian Medicaid,DRG,2222,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$5,962.94 ",IP,"5,962.94","5,962.94",,,,,,,,,,,,
Meridian Medicaid,DRG,2223,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$9,116.74 ",IP,"9,116.74","9,116.74",,,,,,,,,,,,
Meridian Medicaid,DRG,2224,"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",,Relative Weights,"$19,946.46 ",IP,"19,946.46","19,946.46",,,,,,,,,,,,
Meridian Medicaid,DRG,2231,OTHER SMALL & LARGE BOWEL PROCEDURES,,Relative Weights,"$5,180.51 ",IP,"5,180.51","5,180.51",,,,,,,,,,,,
Meridian Medicaid,DRG,2232,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$7,107.90 ",IP,"7,107.90","7,107.90",,,,,,,,,,,,
Meridian Medicaid,DRG,2233,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$10,759.27 ",IP,"10,759.27","10,759.27",,,,,,,,,,,,
Meridian Medicaid,DRG,2234,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$20,449.53 ",IP,"20,449.53","20,449.53",,,,,,,,,,,,
Meridian Medicaid,DRG,2241,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$6,143.69 ",IP,"6,143.69","6,143.69",,,,,,,,,,,,
Meridian Medicaid,DRG,2242,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$7,746.36 ",IP,"7,746.36","7,746.36",,,,,,,,,,,,
Meridian Medicaid,DRG,2243,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$11,242.41 ",IP,"11,242.41","11,242.41",,,,,,,,,,,,
Meridian Medicaid,DRG,2244,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$20,422.04 ",IP,"20,422.04","20,422.04",,,,,,,,,,,,
Meridian Medicaid,DRG,2261,ANAL PROCEDURES,,Relative Weights,"$4,263.71 ",IP,"4,263.71","4,263.71",,,,,,,,,,,,
Meridian Medicaid,DRG,2262,ANAL PROCEDURES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,,,,,,,
Meridian Medicaid,DRG,2263,ANAL PROCEDURES,,Relative Weights,"$7,950.47 ",IP,"7,950.47","7,950.47",,,,,,,,,,,,
Meridian Medicaid,DRG,2264,ANAL PROCEDURES,,Relative Weights,"$17,017.73 ",IP,"17,017.73","17,017.73",,,,,,,,,,,,
Meridian Medicaid,DRG,2271,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$5,689.07 ",IP,"5,689.07","5,689.07",,,,,,,,,,,,
Meridian Medicaid,DRG,2272,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$6,795.89 ",IP,"6,795.89","6,795.89",,,,,,,,,,,,
Meridian Medicaid,DRG,2273,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$10,114.97 ",IP,"10,114.97","10,114.97",,,,,,,,,,,,
Meridian Medicaid,DRG,2274,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$20,038.21 ",IP,"20,038.21","20,038.21",,,,,,,,,,,,
Meridian Medicaid,DRG,2281,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$4,335.53 ",IP,"4,335.53","4,335.53",,,,,,,,,,,,
Meridian Medicaid,DRG,2282,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$5,502.48 ",IP,"5,502.48","5,502.48",,,,,,,,,,,,
Meridian Medicaid,DRG,2283,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$7,788.28 ",IP,"7,788.28","7,788.28",,,,,,,,,,,,
Meridian Medicaid,DRG,2284,"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",,Relative Weights,"$16,501.95 ",IP,"16,501.95","16,501.95",,,,,,,,,,,,
Meridian Medicaid,DRG,2291,OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,,Relative Weights,"$5,564.34 ",IP,"5,564.34","5,564.34",,,,,,,,,,,,
Meridian Medicaid,DRG,2292,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$7,117.87 ",IP,"7,117.87","7,117.87",,,,,,,,,,,,
Meridian Medicaid,DRG,2293,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$10,259.30 ",IP,"10,259.30","10,259.30",,,,,,,,,,,,
Meridian Medicaid,DRG,2294,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$20,018.28 ",IP,"20,018.28","20,018.28",,,,,,,,,,,,
Meridian Medicaid,DRG,2301,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$6,770.12 ",IP,"6,770.12","6,770.12",,,,,,,,,,,,
Meridian Medicaid,DRG,2302,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$8,787.20 ",IP,"8,787.20","8,787.20",,,,,,,,,,,,
Meridian Medicaid,DRG,2303,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$13,506.56 ",IP,"13,506.56","13,506.56",,,,,,,,,,,,
Meridian Medicaid,DRG,2304,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$27,168.10 ",IP,"27,168.10","27,168.10",,,,,,,,,,,,
Meridian Medicaid,DRG,2311,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$6,900.01 ",IP,"6,900.01","6,900.01",,,,,,,,,,,,
Meridian Medicaid,DRG,2312,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$8,451.83 ",IP,"8,451.83","8,451.83",,,,,,,,,,,,
Meridian Medicaid,DRG,2313,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$12,656.43 ",IP,"12,656.43","12,656.43",,,,,,,,,,,,
Meridian Medicaid,DRG,2314,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$23,212.62 ",IP,"23,212.62","23,212.62",,,,,,,,,,,,
Meridian Medicaid,DRG,2321,GASTRIC FUNDOPLICATION,,Relative Weights,"$5,317.96 ",IP,"5,317.96","5,317.96",,,,,,,,,,,,
Meridian Medicaid,DRG,2322,GASTRIC FUNDOPLICATION,,Relative Weights,"$6,619.27 ",IP,"6,619.27","6,619.27",,,,,,,,,,,,
Meridian Medicaid,DRG,2323,GASTRIC FUNDOPLICATION,,Relative Weights,"$9,668.60 ",IP,"9,668.60","9,668.60",,,,,,,,,,,,
Meridian Medicaid,DRG,2324,GASTRIC FUNDOPLICATION,,Relative Weights,"$26,510.06 ",IP,"26,510.06","26,510.06",,,,,,,,,,,,
Meridian Medicaid,DRG,2331,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,328.61 ",IP,"5,328.61","5,328.61",,,,,,,,,,,,
Meridian Medicaid,DRG,2332,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,525.46 ",IP,"6,525.46","6,525.46",,,,,,,,,,,,
Meridian Medicaid,DRG,2333,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,426.35 ",IP,"9,426.35","9,426.35",,,,,,,,,,,,
Meridian Medicaid,DRG,2334,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$16,969.28 ",IP,"16,969.28","16,969.28",,,,,,,,,,,,
Meridian Medicaid,DRG,2341,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,,,,,,,
Meridian Medicaid,DRG,2342,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,853.72 ",IP,"4,853.72","4,853.72",,,,,,,,,,,,
Meridian Medicaid,DRG,2343,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,767.67 ",IP,"7,767.67","7,767.67",,,,,,,,,,,,
Meridian Medicaid,DRG,2344,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$15,153.91 ",IP,"15,153.91","15,153.91",,,,,,,,,,,,
Meridian Medicaid,DRG,2401,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,130.38 ",IP,"4,130.38","4,130.38",,,,,,,,,,,,
Meridian Medicaid,DRG,2402,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,471.61 ",IP,"4,471.61","4,471.61",,,,,,,,,,,,
Meridian Medicaid,DRG,2403,DIGESTIVE MALIGNANCY,,Relative Weights,"$5,940.95 ",IP,"5,940.95","5,940.95",,,,,,,,,,,,
Meridian Medicaid,DRG,2404,DIGESTIVE MALIGNANCY,,Relative Weights,"$10,480.94 ",IP,"10,480.94","10,480.94",,,,,,,,,,,,
Meridian Medicaid,DRG,2411,PEPTIC ULCER & GASTRITIS,,Relative Weights,"$3,142.46 ",IP,"3,142.46","3,142.46",,,,,,,,,,,,
Meridian Medicaid,DRG,2412,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$3,833.49 ",IP,"3,833.49","3,833.49",,,,,,,,,,,,
Meridian Medicaid,DRG,2413,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,,,,,,,
Meridian Medicaid,DRG,2414,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$11,497.38 ",IP,"11,497.38","11,497.38",,,,,,,,,,,,
Meridian Medicaid,DRG,2421,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$2,834.23 ",IP,"2,834.23","2,834.23",,,,,,,,,,,,
Meridian Medicaid,DRG,2422,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$3,630.75 ",IP,"3,630.75","3,630.75",,,,,,,,,,,,
Meridian Medicaid,DRG,2423,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$5,095.29 ",IP,"5,095.29","5,095.29",,,,,,,,,,,,
Meridian Medicaid,DRG,2424,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$11,235.54 ",IP,"11,235.54","11,235.54",,,,,,,,,,,,
Meridian Medicaid,DRG,2431,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$2,619.12 ",IP,"2,619.12","2,619.12",,,,,,,,,,,,
Meridian Medicaid,DRG,2432,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$3,394.34 ",IP,"3,394.34","3,394.34",,,,,,,,,,,,
Meridian Medicaid,DRG,2433,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$4,672.28 ",IP,"4,672.28","4,672.28",,,,,,,,,,,,
Meridian Medicaid,DRG,2434,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$10,028.72 ",IP,"10,028.72","10,028.72",,,,,,,,,,,,
Meridian Medicaid,DRG,2441,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$2,541.46 ",IP,"2,541.46","2,541.46",,,,,,,,,,,,
Meridian Medicaid,DRG,2442,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$3,268.57 ",IP,"3,268.57","3,268.57",,,,,,,,,,,,
Meridian Medicaid,DRG,2443,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$4,670.91 ",IP,"4,670.91","4,670.91",,,,,,,,,,,,
Meridian Medicaid,DRG,2444,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$10,075.80 ",IP,"10,075.80","10,075.80",,,,,,,,,,,,
Meridian Medicaid,DRG,2451,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,109.82 ",IP,"3,109.82","3,109.82",,,,,,,,,,,,
Meridian Medicaid,DRG,2452,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,884.35 ",IP,"3,884.35","3,884.35",,,,,,,,,,,,
Meridian Medicaid,DRG,2453,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$5,370.53 ",IP,"5,370.53","5,370.53",,,,,,,,,,,,
Meridian Medicaid,DRG,2454,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$12,127.25 ",IP,"12,127.25","12,127.25",,,,,,,,,,,,
Meridian Medicaid,DRG,2461,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,009.82 ",IP,"3,009.82","3,009.82",,,,,,,,,,,,
Meridian Medicaid,DRG,2462,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,644.84 ",IP,"3,644.84","3,644.84",,,,,,,,,,,,
Meridian Medicaid,DRG,2463,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$5,068.14 ",IP,"5,068.14","5,068.14",,,,,,,,,,,,
Meridian Medicaid,DRG,2464,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,,,,,,,
Meridian Medicaid,DRG,2471,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,323.60 ",IP,"2,323.60","2,323.60",,,,,,,,,,,,
Meridian Medicaid,DRG,2472,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,999.17 ",IP,"2,999.17","2,999.17",,,,,,,,,,,,
Meridian Medicaid,DRG,2473,INTESTINAL OBSTRUCTION,,Relative Weights,"$4,431.74 ",IP,"4,431.74","4,431.74",,,,,,,,,,,,
Meridian Medicaid,DRG,2474,INTESTINAL OBSTRUCTION,,Relative Weights,"$9,108.15 ",IP,"9,108.15","9,108.15",,,,,,,,,,,,
Meridian Medicaid,DRG,2481,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$2,573.42 ",IP,"2,573.42","2,573.42",,,,,,,,,,,,
Meridian Medicaid,DRG,2482,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$3,590.89 ",IP,"3,590.89","3,590.89",,,,,,,,,,,,
Meridian Medicaid,DRG,2483,MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,,Relative Weights,"$4,839.63 ",IP,"4,839.63","4,839.63",,,,,,,,,,,,
Meridian Medicaid,DRG,2484,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$10,133.19 ",IP,"10,133.19","10,133.19",,,,,,,,,,,,
Meridian Medicaid,DRG,2491,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,187.52 ",IP,"2,187.52","2,187.52",,,,,,,,,,,,
Meridian Medicaid,DRG,2492,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,797.80 ",IP,"2,797.80","2,797.80",,,,,,,,,,,,
Meridian Medicaid,DRG,2493,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$3,754.80 ",IP,"3,754.80","3,754.80",,,,,,,,,,,,
Meridian Medicaid,DRG,2494,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$8,298.22 ",IP,"8,298.22","8,298.22",,,,,,,,,,,,
Meridian Medicaid,DRG,2511,ABDOMINAL PAIN,,Relative Weights,"$2,520.84 ",IP,"2,520.84","2,520.84",,,,,,,,,,,,
Meridian Medicaid,DRG,2512,ABDOMINAL PAIN,,Relative Weights,"$3,175.79 ",IP,"3,175.79","3,175.79",,,,,,,,,,,,
Meridian Medicaid,DRG,2513,ABDOMINAL PAIN,,Relative Weights,"$4,112.86 ",IP,"4,112.86","4,112.86",,,,,,,,,,,,
Meridian Medicaid,DRG,2514,ABDOMINAL PAIN,,Relative Weights,"$7,334.01 ",IP,"7,334.01","7,334.01",,,,,,,,,,,,
Meridian Medicaid,DRG,2521,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$2,913.26 ",IP,"2,913.26","2,913.26",,,,,,,,,,,,
Meridian Medicaid,DRG,2522,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$3,639.34 ",IP,"3,639.34","3,639.34",,,,,,,,,,,,
Meridian Medicaid,DRG,2523,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$5,172.60 ",IP,"5,172.60","5,172.60",,,,,,,,,,,,
Meridian Medicaid,DRG,2524,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$11,168.53 ",IP,"11,168.53","11,168.53",,,,,,,,,,,,
Meridian Medicaid,DRG,2531,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$2,890.24 ",IP,"2,890.24","2,890.24",,,,,,,,,,,,
Meridian Medicaid,DRG,2532,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$3,602.23 ",IP,"3,602.23","3,602.23",,,,,,,,,,,,
Meridian Medicaid,DRG,2533,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$5,054.39 ",IP,"5,054.39","5,054.39",,,,,,,,,,,,
Meridian Medicaid,DRG,2534,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$9,586.48 ",IP,"9,586.48","9,586.48",,,,,,,,,,,,
Meridian Medicaid,DRG,2541,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$2,614.99 ",IP,"2,614.99","2,614.99",,,,,,,,,,,,
Meridian Medicaid,DRG,2542,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$3,386.43 ",IP,"3,386.43","3,386.43",,,,,,,,,,,,
Meridian Medicaid,DRG,2543,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$4,771.93 ",IP,"4,771.93","4,771.93",,,,,,,,,,,,
Meridian Medicaid,DRG,2544,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$9,778.91 ",IP,"9,778.91","9,778.91",,,,,,,,,,,,
Meridian Medicaid,DRG,2601,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$9,438.72 ",IP,"9,438.72","9,438.72",,,,,,,,,,,,
Meridian Medicaid,DRG,2602,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$11,500.13 ",IP,"11,500.13","11,500.13",,,,,,,,,,,,
Meridian Medicaid,DRG,2603,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$16,312.61 ",IP,"16,312.61","16,312.61",,,,,,,,,,,,
Meridian Medicaid,DRG,2604,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$34,324.11 ",IP,"34,324.11","34,324.11",,,,,,,,,,,,
Meridian Medicaid,DRG,2611,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$6,801.05 ",IP,"6,801.05","6,801.05",,,,,,,,,,,,
Meridian Medicaid,DRG,2612,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$10,119.10 ",IP,"10,119.10","10,119.10",,,,,,,,,,,,
Meridian Medicaid,DRG,2613,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$14,491.05 ",IP,"14,491.05","14,491.05",,,,,,,,,,,,
Meridian Medicaid,DRG,2614,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$28,576.97 ",IP,"28,576.97","28,576.97",,,,,,,,,,,,
Meridian Medicaid,DRG,2631,CHOLECYSTECTOMY,,Relative Weights,"$5,153.36 ",IP,"5,153.36","5,153.36",,,,,,,,,,,,
Meridian Medicaid,DRG,2632,CHOLECYSTECTOMY,,Relative Weights,"$6,574.60 ",IP,"6,574.60","6,574.60",,,,,,,,,,,,
Meridian Medicaid,DRG,2633,CHOLECYSTECTOMY,,Relative Weights,"$8,823.28 ",IP,"8,823.28","8,823.28",,,,,,,,,,,,
Meridian Medicaid,DRG,2634,CHOLECYSTECTOMY,,Relative Weights,"$16,983.37 ",IP,"16,983.37","16,983.37",,,,,,,,,,,,
Meridian Medicaid,DRG,2641,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$6,826.47 ",IP,"6,826.47","6,826.47",,,,,,,,,,,,
Meridian Medicaid,DRG,2642,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$7,584.86 ",IP,"7,584.86","7,584.86",,,,,,,,,,,,
Meridian Medicaid,DRG,2643,"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",,Relative Weights,"$11,612.15 ",IP,"11,612.15","11,612.15",,,,,,,,,,,,
Meridian Medicaid,DRG,2644,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$29,218.86 ",IP,"29,218.86","29,218.86",,,,,,,,,,,,
Meridian Medicaid,DRG,2791,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$2,567.92 ",IP,"2,567.92","2,567.92",,,,,,,,,,,,
Meridian Medicaid,DRG,2792,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$3,323.89 ",IP,"3,323.89","3,323.89",,,,,,,,,,,,
Meridian Medicaid,DRG,2793,HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$4,704.93 ",IP,"4,704.93","4,704.93",,,,,,,,,,,,
Meridian Medicaid,DRG,2794,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$11,290.86 ",IP,"11,290.86","11,290.86",,,,,,,,,,,,
Meridian Medicaid,DRG,2801,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$2,499.54 ",IP,"2,499.54","2,499.54",,,,,,,,,,,,
Meridian Medicaid,DRG,2802,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$3,093.32 ",IP,"3,093.32","3,093.32",,,,,,,,,,,,
Meridian Medicaid,DRG,2803,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$4,638.26 ",IP,"4,638.26","4,638.26",,,,,,,,,,,,
Meridian Medicaid,DRG,2804,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$10,324.24 ",IP,"10,324.24","10,324.24",,,,,,,,,,,,
Meridian Medicaid,DRG,2811,MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,,Relative Weights,"$3,619.41 ",IP,"3,619.41","3,619.41",,,,,,,,,,,,
Meridian Medicaid,DRG,2812,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,,,,,,,
Meridian Medicaid,DRG,2813,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$5,844.73 ",IP,"5,844.73","5,844.73",,,,,,,,,,,,
Meridian Medicaid,DRG,2814,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$9,186.50 ",IP,"9,186.50","9,186.50",,,,,,,,,,,,
Meridian Medicaid,DRG,2821,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$2,462.42 ",IP,"2,462.42","2,462.42",,,,,,,,,,,,
Meridian Medicaid,DRG,2822,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,,,,,,,
Meridian Medicaid,DRG,2823,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$4,746.16 ",IP,"4,746.16","4,746.16",,,,,,,,,,,,
Meridian Medicaid,DRG,2824,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$12,503.18 ",IP,"12,503.18","12,503.18",,,,,,,,,,,,
Meridian Medicaid,DRG,2831,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$2,720.83 ",IP,"2,720.83","2,720.83",,,,,,,,,,,,
Meridian Medicaid,DRG,2832,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$3,349.67 ",IP,"3,349.67","3,349.67",,,,,,,,,,,,
Meridian Medicaid,DRG,2833,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$4,885.67 ",IP,"4,885.67","4,885.67",,,,,,,,,,,,
Meridian Medicaid,DRG,2834,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$10,248.65 ",IP,"10,248.65","10,248.65",,,,,,,,,,,,
Meridian Medicaid,DRG,2841,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$3,351.73 ",IP,"3,351.73","3,351.73",,,,,,,,,,,,
Meridian Medicaid,DRG,2842,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$4,147.57 ",IP,"4,147.57","4,147.57",,,,,,,,,,,,
Meridian Medicaid,DRG,2843,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$5,552.31 ",IP,"5,552.31","5,552.31",,,,,,,,,,,,
Meridian Medicaid,DRG,2844,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$10,788.48 ",IP,"10,788.48","10,788.48",,,,,,,,,,,,
Meridian Medicaid,DRG,3011,HIP JOINT REPLACEMENT,,Relative Weights,"$7,771.10 ",IP,"7,771.10","7,771.10",,,,,,,,,,,,
Meridian Medicaid,DRG,3012,HIP JOINT REPLACEMENT,,Relative Weights,"$8,122.29 ",IP,"8,122.29","8,122.29",,,,,,,,,,,,
Meridian Medicaid,DRG,3013,HIP JOINT REPLACEMENT,,Relative Weights,"$10,480.59 ",IP,"10,480.59","10,480.59",,,,,,,,,,,,
Meridian Medicaid,DRG,3014,HIP JOINT REPLACEMENT,,Relative Weights,"$16,617.41 ",IP,"16,617.41","16,617.41",,,,,,,,,,,,
Meridian Medicaid,DRG,3021,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,208.24 ",IP,"7,208.24","7,208.24",,,,,,,,,,,,
Meridian Medicaid,DRG,3022,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,702.03 ",IP,"7,702.03","7,702.03",,,,,,,,,,,,
Meridian Medicaid,DRG,3023,KNEE JOINT REPLACEMENT,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,,,,,,,
Meridian Medicaid,DRG,3024,KNEE JOINT REPLACEMENT,,Relative Weights,"$17,075.12 ",IP,"17,075.12","17,075.12",,,,,,,,,,,,
Meridian Medicaid,DRG,3031,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$22,622.27 ",IP,"22,622.27","22,622.27",,,,,,,,,,,,
Meridian Medicaid,DRG,3032,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$26,401.82 ",IP,"26,401.82","26,401.82",,,,,,,,,,,,
Meridian Medicaid,DRG,3033,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$36,462.15 ",IP,"36,462.15","36,462.15",,,,,,,,,,,,
Meridian Medicaid,DRG,3034,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$46,680.22 ",IP,"46,680.22","46,680.22",,,,,,,,,,,,
Meridian Medicaid,DRG,3041,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$13,662.91 ",IP,"13,662.91","13,662.91",,,,,,,,,,,,
Meridian Medicaid,DRG,3042,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$15,568.66 ",IP,"15,568.66","15,568.66",,,,,,,,,,,,
Meridian Medicaid,DRG,3043,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$23,409.86 ",IP,"23,409.86","23,409.86",,,,,,,,,,,,
Meridian Medicaid,DRG,3044,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$37,522.24 ",IP,"37,522.24","37,522.24",,,,,,,,,,,,
Meridian Medicaid,DRG,3051,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$4,866.09 ",IP,"4,866.09","4,866.09",,,,,,,,,,,,
Meridian Medicaid,DRG,3052,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$6,637.82 ",IP,"6,637.82","6,637.82",,,,,,,,,,,,
Meridian Medicaid,DRG,3053,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$10,080.61 ",IP,"10,080.61","10,080.61",,,,,,,,,,,,
Meridian Medicaid,DRG,3054,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$19,786.33 ",IP,"19,786.33","19,786.33",,,,,,,,,,,,
Meridian Medicaid,DRG,3081,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$6,633.70 ",IP,"6,633.70","6,633.70",,,,,,,,,,,,
Meridian Medicaid,DRG,3082,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$7,529.88 ",IP,"7,529.88","7,529.88",,,,,,,,,,,,
Meridian Medicaid,DRG,3083,HIP & FEMUR FRACTURE REPAIR,,Relative Weights,"$9,249.72 ",IP,"9,249.72","9,249.72",,,,,,,,,,,,
Meridian Medicaid,DRG,3084,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$14,744.30 ",IP,"14,744.30","14,744.30",,,,,,,,,,,,
Meridian Medicaid,DRG,3091,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$7,238.83 ",IP,"7,238.83","7,238.83",,,,,,,,,,,,
Meridian Medicaid,DRG,3092,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$9,130.83 ",IP,"9,130.83","9,130.83",,,,,,,,,,,,
Meridian Medicaid,DRG,3093,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$12,063.33 ",IP,"12,063.33","12,063.33",,,,,,,,,,,,
Meridian Medicaid,DRG,3094,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$21,019.95 ",IP,"21,019.95","21,019.95",,,,,,,,,,,,
Meridian Medicaid,DRG,3101,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$5,634.78 ",IP,"5,634.78","5,634.78",,,,,,,,,,,,
Meridian Medicaid,DRG,3102,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$6,775.27 ",IP,"6,775.27","6,775.27",,,,,,,,,,,,
Meridian Medicaid,DRG,3103,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$9,328.07 ",IP,"9,328.07","9,328.07",,,,,,,,,,,,
Meridian Medicaid,DRG,3104,INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,,Relative Weights,"$18,301.18 ",IP,"18,301.18","18,301.18",,,,,,,,,,,,
Meridian Medicaid,DRG,3121,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$6,515.49 ",IP,"6,515.49","6,515.49",,,,,,,,,,,,
Meridian Medicaid,DRG,3122,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,587.21 ",IP,"8,587.21","8,587.21",,,,,,,,,,,,
Meridian Medicaid,DRG,3123,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$12,636.50 ",IP,"12,636.50","12,636.50",,,,,,,,,,,,
Meridian Medicaid,DRG,3124,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$31,602.60 ",IP,"31,602.60","31,602.60",,,,,,,,,,,,
Meridian Medicaid,DRG,3131,KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$5,906.59 ",IP,"5,906.59","5,906.59",,,,,,,,,,,,
Meridian Medicaid,DRG,3132,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$7,791.03 ",IP,"7,791.03","7,791.03",,,,,,,,,,,,
Meridian Medicaid,DRG,3133,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$10,674.40 ",IP,"10,674.40","10,674.40",,,,,,,,,,,,
Meridian Medicaid,DRG,3134,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$18,704.94 ",IP,"18,704.94","18,704.94",,,,,,,,,,,,
Meridian Medicaid,DRG,3141,FOOT & TOE PROCEDURES,,Relative Weights,"$5,184.29 ",IP,"5,184.29","5,184.29",,,,,,,,,,,,
Meridian Medicaid,DRG,3142,FOOT and TOE PROCEDURES,,Relative Weights,"$5,760.89 ",IP,"5,760.89","5,760.89",,,,,,,,,,,,
Meridian Medicaid,DRG,3143,FOOT and TOE PROCEDURES,,Relative Weights,"$7,587.61 ",IP,"7,587.61","7,587.61",,,,,,,,,,,,
Meridian Medicaid,DRG,3144,FOOT and TOE PROCEDURES,,Relative Weights,"$15,541.86 ",IP,"15,541.86","15,541.86",,,,,,,,,,,,
Meridian Medicaid,DRG,3151,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$4,407.35 ",IP,"4,407.35","4,407.35",,,,,,,,,,,,
Meridian Medicaid,DRG,3152,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$7,204.46 ",IP,"7,204.46","7,204.46",,,,,,,,,,,,
Meridian Medicaid,DRG,3153,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$9,814.99 ",IP,"9,814.99","9,814.99",,,,,,,,,,,,
Meridian Medicaid,DRG,3154,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$17,630.42 ",IP,"17,630.42","17,630.42",,,,,,,,,,,,
Meridian Medicaid,DRG,3161,HAND and WRIST PROCEDURES,,Relative Weights,"$4,228.66 ",IP,"4,228.66","4,228.66",,,,,,,,,,,,
Meridian Medicaid,DRG,3162,HAND and WRIST PROCEDURES,,Relative Weights,"$5,513.82 ",IP,"5,513.82","5,513.82",,,,,,,,,,,,
Meridian Medicaid,DRG,3163,HAND and WRIST PROCEDURES,,Relative Weights,"$8,327.78 ",IP,"8,327.78","8,327.78",,,,,,,,,,,,
Meridian Medicaid,DRG,3164,HAND and WRIST PROCEDURES,,Relative Weights,"$17,742.44 ",IP,"17,742.44","17,742.44",,,,,,,,,,,,
Meridian Medicaid,DRG,3171,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$4,914.20 ",IP,"4,914.20","4,914.20",,,,,,,,,,,,
Meridian Medicaid,DRG,3172,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$6,410.69 ",IP,"6,410.69","6,410.69",,,,,,,,,,,,
Meridian Medicaid,DRG,3173,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$9,611.56 ",IP,"9,611.56","9,611.56",,,,,,,,,,,,
Meridian Medicaid,DRG,3174,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$20,290.08 ",IP,"20,290.08","20,290.08",,,,,,,,,,,,
Meridian Medicaid,DRG,3201,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$5,415.55 ",IP,"5,415.55","5,415.55",,,,,,,,,,,,
Meridian Medicaid,DRG,3202,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$6,995.19 ",IP,"6,995.19","6,995.19",,,,,,,,,,,,
Meridian Medicaid,DRG,3203,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$10,390.22 ",IP,"10,390.22","10,390.22",,,,,,,,,,,,
Meridian Medicaid,DRG,3204,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$19,965.01 ",IP,"19,965.01","19,965.01",,,,,,,,,,,,
Meridian Medicaid,DRG,3211,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$8,441.17 ",IP,"8,441.17","8,441.17",,,,,,,,,,,,
Meridian Medicaid,DRG,3212,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$10,023.57 ",IP,"10,023.57","10,023.57",,,,,,,,,,,,
Meridian Medicaid,DRG,3213,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$14,027.50 ",IP,"14,027.50","14,027.50",,,,,,,,,,,,
Meridian Medicaid,DRG,3214,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$25,569.90 ",IP,"25,569.90","25,569.90",,,,,,,,,,,,
Meridian Medicaid,DRG,3221,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,466.60 ",IP,"8,466.60","8,466.60",,,,,,,,,,,,
Meridian Medicaid,DRG,3222,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,,,,,,,
Meridian Medicaid,DRG,3223,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$11,526.59 ",IP,"11,526.59","11,526.59",,,,,,,,,,,,
Meridian Medicaid,DRG,3224,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$17,494.69 ",IP,"17,494.69","17,494.69",,,,,,,,,,,,
Meridian Medicaid,DRG,3401,FRACTURE OF FEMUR,,Relative Weights,"$2,284.43 ",IP,"2,284.43","2,284.43",,,,,,,,,,,,
Meridian Medicaid,DRG,3402,FRACTURE OF FEMUR,,Relative Weights,"$2,649.70 ",IP,"2,649.70","2,649.70",,,,,,,,,,,,
Meridian Medicaid,DRG,3403,FRACTURE OF FEMUR,,Relative Weights,"$3,664.08 ",IP,"3,664.08","3,664.08",,,,,,,,,,,,
Meridian Medicaid,DRG,3404,FRACTURE OF FEMUR,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,,,,,,,
Meridian Medicaid,DRG,3411,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,584.41 ",IP,"2,584.41","2,584.41",,,,,,,,,,,,
Meridian Medicaid,DRG,3412,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,958.62 ",IP,"2,958.62","2,958.62",,,,,,,,,,,,
Meridian Medicaid,DRG,3413,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$3,751.71 ",IP,"3,751.71","3,751.71",,,,,,,,,,,,
Meridian Medicaid,DRG,3414,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$8,259.05 ",IP,"8,259.05","8,259.05",,,,,,,,,,,,
Meridian Medicaid,DRG,3421,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$2,677.53 ",IP,"2,677.53","2,677.53",,,,,,,,,,,,
Meridian Medicaid,DRG,3422,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$3,262.04 ",IP,"3,262.04","3,262.04",,,,,,,,,,,,
Meridian Medicaid,DRG,3423,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$4,236.57 ",IP,"4,236.57","4,236.57",,,,,,,,,,,,
Meridian Medicaid,DRG,3424,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$8,410.59 ",IP,"8,410.59","8,410.59",,,,,,,,,,,,
Meridian Medicaid,DRG,3431,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,528.30 ",IP,"4,528.30","4,528.30",,,,,,,,,,,,
Meridian Medicaid,DRG,3432,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,916.60 ",IP,"4,916.60","4,916.60",,,,,,,,,,,,
Meridian Medicaid,DRG,3433,MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,,Relative Weights,"$6,907.57 ",IP,"6,907.57","6,907.57",,,,,,,,,,,,
Meridian Medicaid,DRG,3434,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$11,710.09 ",IP,"11,710.09","11,710.09",,,,,,,,,,,,
Meridian Medicaid,DRG,3441,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$3,603.61 ",IP,"3,603.61","3,603.61",,,,,,,,,,,,
Meridian Medicaid,DRG,3442,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$4,272.99 ",IP,"4,272.99","4,272.99",,,,,,,,,,,,
Meridian Medicaid,DRG,3443,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$5,859.85 ",IP,"5,859.85","5,859.85",,,,,,,,,,,,
Meridian Medicaid,DRG,3444,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$10,885.73 ",IP,"10,885.73","10,885.73",,,,,,,,,,,,
Meridian Medicaid,DRG,3461,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$3,601.54 ",IP,"3,601.54","3,601.54",,,,,,,,,,,,
Meridian Medicaid,DRG,3462,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$4,539.99 ",IP,"4,539.99","4,539.99",,,,,,,,,,,,
Meridian Medicaid,DRG,3463,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$6,445.74 ",IP,"6,445.74","6,445.74",,,,,,,,,,,,
Meridian Medicaid,DRG,3464,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$15,116.11 ",IP,"15,116.11","15,116.11",,,,,,,,,,,,
Meridian Medicaid,DRG,3471,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$3,279.91 ",IP,"3,279.91","3,279.91",,,,,,,,,,,,
Meridian Medicaid,DRG,3472,"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",,Relative Weights,"$3,772.33 ",IP,"3,772.33","3,772.33",,,,,,,,,,,,
Meridian Medicaid,DRG,3473,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$4,894.95 ",IP,"4,894.95","4,894.95",,,,,,,,,,,,
Meridian Medicaid,DRG,3474,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,,,,,,,
Meridian Medicaid,DRG,3491,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$2,603.31 ",IP,"2,603.31","2,603.31",,,,,,,,,,,,
Meridian Medicaid,DRG,3492,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$3,535.91 ",IP,"3,535.91","3,535.91",,,,,,,,,,,,
Meridian Medicaid,DRG,3493,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$5,006.97 ",IP,"5,006.97","5,006.97",,,,,,,,,,,,
Meridian Medicaid,DRG,3494,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$9,666.89 ",IP,"9,666.89","9,666.89",,,,,,,,,,,,
Meridian Medicaid,DRG,3511,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,,,,,,,
Meridian Medicaid,DRG,3512,OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$3,066.17 ",IP,"3,066.17","3,066.17",,,,,,,,,,,,
Meridian Medicaid,DRG,3513,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$4,449.61 ",IP,"4,449.61","4,449.61",,,,,,,,,,,,
Meridian Medicaid,DRG,3514,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,785.14 ",IP,"8,785.14","8,785.14",,,,,,,,,,,,
Meridian Medicaid,DRG,3611,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,,,,,,,
Meridian Medicaid,DRG,3612,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$6,759.47 ",IP,"6,759.47","6,759.47",,,,,,,,,,,,
Meridian Medicaid,DRG,3613,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$10,411.18 ",IP,"10,411.18","10,411.18",,,,,,,,,,,,
Meridian Medicaid,DRG,3614,SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$23,051.12 ",IP,"23,051.12","23,051.12",,,,,,,,,,,,
Meridian Medicaid,DRG,3621,MASTECTOMY PROCEDURES,,Relative Weights,"$5,733.06 ",IP,"5,733.06","5,733.06",,,,,,,,,,,,
Meridian Medicaid,DRG,3622,MASTECTOMY PROCEDURES,,Relative Weights,"$6,783.86 ",IP,"6,783.86","6,783.86",,,,,,,,,,,,
Meridian Medicaid,DRG,3623,MASTECTOMY PROCEDURES,,Relative Weights,"$8,730.85 ",IP,"8,730.85","8,730.85",,,,,,,,,,,,
Meridian Medicaid,DRG,3624,MASTECTOMY PROCEDURES,,Relative Weights,"$15,662.13 ",IP,"15,662.13","15,662.13",,,,,,,,,,,,
Meridian Medicaid,DRG,3631,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$5,772.23 ",IP,"5,772.23","5,772.23",,,,,,,,,,,,
Meridian Medicaid,DRG,3632,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$7,919.20 ",IP,"7,919.20","7,919.20",,,,,,,,,,,,
Meridian Medicaid,DRG,3633,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$10,641.07 ",IP,"10,641.07","10,641.07",,,,,,,,,,,,
Meridian Medicaid,DRG,3634,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$13,007.96 ",IP,"13,007.96","13,007.96",,,,,,,,,,,,
Meridian Medicaid,DRG,3641,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$3,659.27 ",IP,"3,659.27","3,659.27",,,,,,,,,,,,
Meridian Medicaid,DRG,3642,"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",,Relative Weights,"$5,232.39 ",IP,"5,232.39","5,232.39",,,,,,,,,,,,
Meridian Medicaid,DRG,3643,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$8,152.18 ",IP,"8,152.18","8,152.18",,,,,,,,,,,,
Meridian Medicaid,DRG,3644,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$16,685.79 ",IP,"16,685.79","16,685.79",,,,,,,,,,,,
Meridian Medicaid,DRG,3801,SKIN ULCERS,,Relative Weights,"$2,950.72 ",IP,"2,950.72","2,950.72",,,,,,,,,,,,
Meridian Medicaid,DRG,3802,SKIN ULCERS,,Relative Weights,"$3,415.64 ",IP,"3,415.64","3,415.64",,,,,,,,,,,,
Meridian Medicaid,DRG,3803,SKIN ULCERS,,Relative Weights,"$4,667.13 ",IP,"4,667.13","4,667.13",,,,,,,,,,,,
Meridian Medicaid,DRG,3804,SKIN ULCERS,,Relative Weights,"$9,197.15 ",IP,"9,197.15","9,197.15",,,,,,,,,,,,
Meridian Medicaid,DRG,3811,MAJOR SKIN DISORDERS,,Relative Weights,"$2,135.64 ",IP,"2,135.64","2,135.64",,,,,,,,,,,,
Meridian Medicaid,DRG,3812,MAJOR SKIN DISORDERS,,Relative Weights,"$3,426.98 ",IP,"3,426.98","3,426.98",,,,,,,,,,,,
Meridian Medicaid,DRG,3813,MAJOR SKIN DISORDERS,,Relative Weights,"$6,058.47 ",IP,"6,058.47","6,058.47",,,,,,,,,,,,
Meridian Medicaid,DRG,3814,MAJOR SKIN DISORDERS,,Relative Weights,"$15,997.51 ",IP,"15,997.51","15,997.51",,,,,,,,,,,,
Meridian Medicaid,DRG,3821,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,708.41 ",IP,"3,708.41","3,708.41",,,,,,,,,,,,
Meridian Medicaid,DRG,3822,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,,,,,,,
Meridian Medicaid,DRG,3823,MALIGNANT BREAST DISORDERS,,Relative Weights,"$5,221.05 ",IP,"5,221.05","5,221.05",,,,,,,,,,,,
Meridian Medicaid,DRG,3824,MALIGNANT BREAST DISORDERS,,Relative Weights,"$8,582.75 ",IP,"8,582.75","8,582.75",,,,,,,,,,,,
Meridian Medicaid,DRG,3831,CELLULITIS & OTHER SKIN INFECTIONS,,Relative Weights,"$2,128.08 ",IP,"2,128.08","2,128.08",,,,,,,,,,,,
Meridian Medicaid,DRG,3832,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$2,886.11 ",IP,"2,886.11","2,886.11",,,,,,,,,,,,
Meridian Medicaid,DRG,3833,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$4,151.00 ",IP,"4,151.00","4,151.00",,,,,,,,,,,,
Meridian Medicaid,DRG,3834,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$8,552.16 ",IP,"8,552.16","8,552.16",,,,,,,,,,,,
Meridian Medicaid,DRG,3841,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$2,690.94 ",IP,"2,690.94","2,690.94",,,,,,,,,,,,
Meridian Medicaid,DRG,3842,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$3,464.09 ",IP,"3,464.09","3,464.09",,,,,,,,,,,,
Meridian Medicaid,DRG,3843,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$4,737.92 ",IP,"4,737.92","4,737.92",,,,,,,,,,,,
Meridian Medicaid,DRG,3844,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$9,439.41 ",IP,"9,439.41","9,439.41",,,,,,,,,,,,
Meridian Medicaid,DRG,3851,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,189.24 ",IP,"2,189.24","2,189.24",,,,,,,,,,,,
Meridian Medicaid,DRG,3852,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,880.96 ",IP,"2,880.96","2,880.96",,,,,,,,,,,,
Meridian Medicaid,DRG,3853,"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",,Relative Weights,"$4,186.05 ",IP,"4,186.05","4,186.05",,,,,,,,,,,,
Meridian Medicaid,DRG,3854,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$8,871.05 ",IP,"8,871.05","8,871.05",,,,,,,,,,,,
Meridian Medicaid,DRG,4011,ADRENAL PROCEDURES,,Relative Weights,"$6,855.68 ",IP,"6,855.68","6,855.68",,,,,,,,,,,,
Meridian Medicaid,DRG,4012,ADRENAL PROCEDURES,,Relative Weights,"$10,778.52 ",IP,"10,778.52","10,778.52",,,,,,,,,,,,
Meridian Medicaid,DRG,4013,ADRENAL PROCEDURES,,Relative Weights,"$13,300.04 ",IP,"13,300.04","13,300.04",,,,,,,,,,,,
Meridian Medicaid,DRG,4014,ADRENAL PROCEDURES,,Relative Weights,"$24,027.70 ",IP,"24,027.70","24,027.70",,,,,,,,,,,,
Meridian Medicaid,DRG,4031,PROCEDURES FOR OBESITY,,Relative Weights,"$5,110.06 ",IP,"5,110.06","5,110.06",,,,,,,,,,,,
Meridian Medicaid,DRG,4032,PROCEDURES FOR OBESITY,,Relative Weights,"$6,108.30 ",IP,"6,108.30","6,108.30",,,,,,,,,,,,
Meridian Medicaid,DRG,4033,PROCEDURES FOR OBESITY,,Relative Weights,"$9,074.13 ",IP,"9,074.13","9,074.13",,,,,,,,,,,,
Meridian Medicaid,DRG,4034,PROCEDURES FOR OBESITY,,Relative Weights,"$26,392.19 ",IP,"26,392.19","26,392.19",,,,,,,,,,,,
Meridian Medicaid,DRG,4041,"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",,Relative Weights,"$4,728.64 ",IP,"4,728.64","4,728.64",,,,,,,,,,,,
Meridian Medicaid,DRG,4042,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,,,,,,,
Meridian Medicaid,DRG,4043,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$10,989.85 ",IP,"10,989.85","10,989.85",,,,,,,,,,,,
Meridian Medicaid,DRG,4044,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$24,206.39 ",IP,"24,206.39","24,206.39",,,,,,,,,,,,
Meridian Medicaid,DRG,4051,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$7,505.82 ",IP,"7,505.82","7,505.82",,,,,,,,,,,,
Meridian Medicaid,DRG,4052,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$8,475.19 ",IP,"8,475.19","8,475.19",,,,,,,,,,,,
Meridian Medicaid,DRG,4053,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$12,612.79 ",IP,"12,612.79","12,612.79",,,,,,,,,,,,
Meridian Medicaid,DRG,4054,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$26,164.03 ",IP,"26,164.03","26,164.03",,,,,,,,,,,,
Meridian Medicaid,DRG,4201,DIABETES,,Relative Weights,"$2,259.68 ",IP,"2,259.68","2,259.68",,,,,,,,,,,,
Meridian Medicaid,DRG,4202,DIABETES,,Relative Weights,"$2,723.24 ",IP,"2,723.24","2,723.24",,,,,,,,,,,,
Meridian Medicaid,DRG,4203,DIABETES,,Relative Weights,"$3,776.79 ",IP,"3,776.79","3,776.79",,,,,,,,,,,,
Meridian Medicaid,DRG,4204,DIABETES,,Relative Weights,"$8,028.82 ",IP,"8,028.82","8,028.82",,,,,,,,,,,,
Meridian Medicaid,DRG,4211,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$2,343.53 ",IP,"2,343.53","2,343.53",,,,,,,,,,,,
Meridian Medicaid,DRG,4212,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$3,329.74 ",IP,"3,329.74","3,329.74",,,,,,,,,,,,
Meridian Medicaid,DRG,4213,"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",,Relative Weights,"$5,181.88 ",IP,"5,181.88","5,181.88",,,,,,,,,,,,
Meridian Medicaid,DRG,4214,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$10,295.72 ",IP,"10,295.72","10,295.72",,,,,,,,,,,,
Meridian Medicaid,DRG,4221,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$1,870.01 ",IP,"1,870.01","1,870.01",,,,,,,,,,,,
Meridian Medicaid,DRG,4222,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$2,609.84 ",IP,"2,609.84","2,609.84",,,,,,,,,,,,
Meridian Medicaid,DRG,4223,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$3,459.28 ",IP,"3,459.28","3,459.28",,,,,,,,,,,,
Meridian Medicaid,DRG,4224,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,,,,,,,
Meridian Medicaid,DRG,4231,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,529.29 ",IP,"5,529.29","5,529.29",,,,,,,,,,,,
Meridian Medicaid,DRG,4232,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,948.85 ",IP,"5,948.85","5,948.85",,,,,,,,,,,,
Meridian Medicaid,DRG,4233,INBORN ERRORS OF METABOLISM,,Relative Weights,"$8,447.01 ",IP,"8,447.01","8,447.01",,,,,,,,,,,,
Meridian Medicaid,DRG,4234,INBORN ERRORS OF METABOLISM,,Relative Weights,"$27,194.91 ",IP,"27,194.91","27,194.91",,,,,,,,,,,,
Meridian Medicaid,DRG,4241,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$2,869.62 ",IP,"2,869.62","2,869.62",,,,,,,,,,,,
Meridian Medicaid,DRG,4242,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$3,662.02 ",IP,"3,662.02","3,662.02",,,,,,,,,,,,
Meridian Medicaid,DRG,4243,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,,,,,,,
Meridian Medicaid,DRG,4244,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$10,807.73 ",IP,"10,807.73","10,807.73",,,,,,,,,,,,
Meridian Medicaid,DRG,4251,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,221.89 ",IP,"2,221.89","2,221.89",,,,,,,,,,,,
Meridian Medicaid,DRG,4252,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,908.79 ",IP,"2,908.79","2,908.79",,,,,,,,,,,,
Meridian Medicaid,DRG,4253,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$3,943.11 ",IP,"3,943.11","3,943.11",,,,,,,,,,,,
Meridian Medicaid,DRG,4254,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$7,662.17 ",IP,"7,662.17","7,662.17",,,,,,,,,,,,
Meridian Medicaid,DRG,4261,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,409.16 ",IP,"2,409.16","2,409.16",,,,,,,,,,,,
Meridian Medicaid,DRG,4262,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,941.78 ",IP,"2,941.78","2,941.78",,,,,,,,,,,,
Meridian Medicaid,DRG,4263,NON-HYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$4,191.21 ",IP,"4,191.21","4,191.21",,,,,,,,,,,,
Meridian Medicaid,DRG,4264,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$8,224.69 ",IP,"8,224.69","8,224.69",,,,,,,,,,,,
Meridian Medicaid,DRG,4271,THYROID DISORDERS,,Relative Weights,"$2,411.91 ",IP,"2,411.91","2,411.91",,,,,,,,,,,,
Meridian Medicaid,DRG,4272,THYROID DISORDERS,,Relative Weights,"$3,208.44 ",IP,"3,208.44","3,208.44",,,,,,,,,,,,
Meridian Medicaid,DRG,4273,THYROID DISORDERS,,Relative Weights,"$4,621.77 ",IP,"4,621.77","4,621.77",,,,,,,,,,,,
Meridian Medicaid,DRG,4274,THYROID DISORDERS,,Relative Weights,"$9,834.92 ",IP,"9,834.92","9,834.92",,,,,,,,,,,,
Meridian Medicaid,DRG,4401,KIDNEY TRANSPLANT,,Relative Weights,"$26,376.39 ",IP,"26,376.39","26,376.39",,,,,,,,,,,,
Meridian Medicaid,DRG,4402,KIDNEY TRANSPLANT,,Relative Weights,"$28,441.58 ",IP,"28,441.58","28,441.58",,,,,,,,,,,,
Meridian Medicaid,DRG,4403,KIDNEY TRANSPLANT,,Relative Weights,"$31,863.75 ",IP,"31,863.75","31,863.75",,,,,,,,,,,,
Meridian Medicaid,DRG,4404,KIDNEY TRANSPLANT,,Relative Weights,"$48,433.40 ",IP,"48,433.40","48,433.40",,,,,,,,,,,,
Meridian Medicaid,DRG,4411,MAJOR BLADDER PROCEDURES,,Relative Weights,"$7,124.74 ",IP,"7,124.74","7,124.74",,,,,,,,,,,,
Meridian Medicaid,DRG,4412,MAJOR BLADDER PROCEDURES,,Relative Weights,"$11,337.94 ",IP,"11,337.94","11,337.94",,,,,,,,,,,,
Meridian Medicaid,DRG,4413,MAJOR BLADDER PROCEDURES,,Relative Weights,"$14,853.23 ",IP,"14,853.23","14,853.23",,,,,,,,,,,,
Meridian Medicaid,DRG,4414,MAJOR BLADDER PROCEDURES,,Relative Weights,"$32,299.47 ",IP,"32,299.47","32,299.47",,,,,,,,,,,,
Meridian Medicaid,DRG,4421,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,007.22 ",IP,"7,007.22","7,007.22",,,,,,,,,,,,
Meridian Medicaid,DRG,4422,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,784.16 ",IP,"7,784.16","7,784.16",,,,,,,,,,,,
Meridian Medicaid,DRG,4423,KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$11,551.33 ",IP,"11,551.33","11,551.33",,,,,,,,,,,,
Meridian Medicaid,DRG,4424,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$20,973.56 ",IP,"20,973.56","20,973.56",,,,,,,,,,,,
Meridian Medicaid,DRG,4431,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$5,745.77 ",IP,"5,745.77","5,745.77",,,,,,,,,,,,
Meridian Medicaid,DRG,4432,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$6,928.19 ",IP,"6,928.19","6,928.19",,,,,,,,,,,,
Meridian Medicaid,DRG,4433,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$10,300.53 ",IP,"10,300.53","10,300.53",,,,,,,,,,,,
Meridian Medicaid,DRG,4434,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$21,259.80 ",IP,"21,259.80","21,259.80",,,,,,,,,,,,
Meridian Medicaid,DRG,4441,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$6,643.67 ",IP,"6,643.67","6,643.67",,,,,,,,,,,,
Meridian Medicaid,DRG,4442,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$8,351.49 ",IP,"8,351.49","8,351.49",,,,,,,,,,,,
Meridian Medicaid,DRG,4443,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$12,840.62 ",IP,"12,840.62","12,840.62",,,,,,,,,,,,
Meridian Medicaid,DRG,4444,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$25,251.70 ",IP,"25,251.70","25,251.70",,,,,,,,,,,,
Meridian Medicaid,DRG,4451,OTHER BLADDER PROCEDURES,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,,,,,,,
Meridian Medicaid,DRG,4452,OTHER BLADDER PROCEDURES,,Relative Weights,"$6,607.93 ",IP,"6,607.93","6,607.93",,,,,,,,,,,,
Meridian Medicaid,DRG,4453,OTHER BLADDER PROCEDURES,,Relative Weights,"$8,634.63 ",IP,"8,634.63","8,634.63",,,,,,,,,,,,
Meridian Medicaid,DRG,4454,OTHER BLADDER PROCEDURES,,Relative Weights,"$17,913.22 ",IP,"17,913.22","17,913.22",,,,,,,,,,,,
Meridian Medicaid,DRG,4461,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$4,096.37 ",IP,"4,096.37","4,096.37",,,,,,,,,,,,
Meridian Medicaid,DRG,4462,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$5,093.91 ",IP,"5,093.91","5,093.91",,,,,,,,,,,,
Meridian Medicaid,DRG,4463,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$7,454.97 ",IP,"7,454.97","7,454.97",,,,,,,,,,,,
Meridian Medicaid,DRG,4464,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$15,279.67 ",IP,"15,279.67","15,279.67",,,,,,,,,,,,
Meridian Medicaid,DRG,4471,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$6,383.54 ",IP,"6,383.54","6,383.54",,,,,,,,,,,,
Meridian Medicaid,DRG,4472,"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",,Relative Weights,"$7,988.27 ",IP,"7,988.27","7,988.27",,,,,,,,,,,,
Meridian Medicaid,DRG,4473,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$11,578.48 ",IP,"11,578.48","11,578.48",,,,,,,,,,,,
Meridian Medicaid,DRG,4474,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$26,335.15 ",IP,"26,335.15","26,335.15",,,,,,,,,,,,
Meridian Medicaid,DRG,4611,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,213.89 ",IP,"4,213.89","4,213.89",,,,,,,,,,,,
Meridian Medicaid,DRG,4612,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,354.09 ",IP,"4,354.09","4,354.09",,,,,,,,,,,,
Meridian Medicaid,DRG,4613,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$5,833.40 ",IP,"5,833.40","5,833.40",,,,,,,,,,,,
Meridian Medicaid,DRG,4614,KIDNEY & URINARY TRACT MALIGNANCY,,Relative Weights,"$10,495.71 ",IP,"10,495.71","10,495.71",,,,,,,,,,,,
Meridian Medicaid,DRG,4621,NEPHRITIS and NEPHROSIS,,Relative Weights,"$2,361.40 ",IP,"2,361.40","2,361.40",,,,,,,,,,,,
Meridian Medicaid,DRG,4622,NEPHRITIS and NEPHROSIS,,Relative Weights,"$3,007.07 ",IP,"3,007.07","3,007.07",,,,,,,,,,,,
Meridian Medicaid,DRG,4623,NEPHRITIS and NEPHROSIS,,Relative Weights,"$5,343.04 ",IP,"5,343.04","5,343.04",,,,,,,,,,,,
Meridian Medicaid,DRG,4624,NEPHRITIS and NEPHROSIS,,Relative Weights,"$14,645.34 ",IP,"14,645.34","14,645.34",,,,,,,,,,,,
Meridian Medicaid,DRG,4631,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,386.48 ",IP,"2,386.48","2,386.48",,,,,,,,,,,,
Meridian Medicaid,DRG,4632,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,925.29 ",IP,"2,925.29","2,925.29",,,,,,,,,,,,
Meridian Medicaid,DRG,4633,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$3,755.49 ",IP,"3,755.49","3,755.49",,,,,,,,,,,,
Meridian Medicaid,DRG,4634,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$6,746.75 ",IP,"6,746.75","6,746.75",,,,,,,,,,,,
Meridian Medicaid,DRG,4651,URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$2,676.16 ",IP,"2,676.16","2,676.16",,,,,,,,,,,,
Meridian Medicaid,DRG,4652,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$3,212.22 ",IP,"3,212.22","3,212.22",,,,,,,,,,,,
Meridian Medicaid,DRG,4653,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$4,385.36 ",IP,"4,385.36","4,385.36",,,,,,,,,,,,
Meridian Medicaid,DRG,4654,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,,,,,,,
Meridian Medicaid,DRG,4661,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$2,602.62 ",IP,"2,602.62","2,602.62",,,,,,,,,,,,
Meridian Medicaid,DRG,4662,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$3,336.61 ",IP,"3,336.61","3,336.61",,,,,,,,,,,,
Meridian Medicaid,DRG,4663,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$4,821.07 ",IP,"4,821.07","4,821.07",,,,,,,,,,,,
Meridian Medicaid,DRG,4664,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$8,281.73 ",IP,"8,281.73","8,281.73",,,,,,,,,,,,
Meridian Medicaid,DRG,4681,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$2,645.58 ",IP,"2,645.58","2,645.58",,,,,,,,,,,,
Meridian Medicaid,DRG,4682,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$3,341.08 ",IP,"3,341.08","3,341.08",,,,,,,,,,,,
Meridian Medicaid,DRG,4683,"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",,Relative Weights,"$4,559.92 ",IP,"4,559.92","4,559.92",,,,,,,,,,,,
Meridian Medicaid,DRG,4684,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$9,588.20 ",IP,"9,588.20","9,588.20",,,,,,,,,,,,
Meridian Medicaid,DRG,4691,ACUTE KIDNEY INJURY,,Relative Weights,"$2,379.95 ",IP,"2,379.95","2,379.95",,,,,,,,,,,,
Meridian Medicaid,DRG,4692,ACUTE KIDNEY INJURY,,Relative Weights,"$3,050.71 ",IP,"3,050.71","3,050.71",,,,,,,,,,,,
Meridian Medicaid,DRG,4693,ACUTE KIDNEY INJURY,,Relative Weights,"$4,563.35 ",IP,"4,563.35","4,563.35",,,,,,,,,,,,
Meridian Medicaid,DRG,4694,ACUTE KIDNEY INJURY,,Relative Weights,"$9,568.95 ",IP,"9,568.95","9,568.95",,,,,,,,,,,,
Meridian Medicaid,DRG,4701,CHRONIC KIDNEY DISEASE,,Relative Weights,"$2,503.66 ",IP,"2,503.66","2,503.66",,,,,,,,,,,,
Meridian Medicaid,DRG,4702,CHRONIC KIDNEY DISEASE,,Relative Weights,"$3,283.35 ",IP,"3,283.35","3,283.35",,,,,,,,,,,,
Meridian Medicaid,DRG,4703,CHRONIC KIDNEY DISEASE,,Relative Weights,"$4,530.02 ",IP,"4,530.02","4,530.02",,,,,,,,,,,,
Meridian Medicaid,DRG,4704,CHRONIC KIDNEY DISEASE,,Relative Weights,"$8,193.42 ",IP,"8,193.42","8,193.42",,,,,,,,,,,,
Meridian Medicaid,DRG,4801,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,131.66 ",IP,"6,131.66","6,131.66",,,,,,,,,,,,
Meridian Medicaid,DRG,4802,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,485.60 ",IP,"6,485.60","6,485.60",,,,,,,,,,,,
Meridian Medicaid,DRG,4803,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$10,188.85 ",IP,"10,188.85","10,188.85",,,,,,,,,,,,
Meridian Medicaid,DRG,4804,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$21,900.66 ",IP,"21,900.66","21,900.66",,,,,,,,,,,,
Meridian Medicaid,DRG,4821,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,027.30 ",IP,"4,027.30","4,027.30",,,,,,,,,,,,
Meridian Medicaid,DRG,4822,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,459.58 ",IP,"4,459.58","4,459.58",,,,,,,,,,,,
Meridian Medicaid,DRG,4823,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$7,759.08 ",IP,"7,759.08","7,759.08",,,,,,,,,,,,
Meridian Medicaid,DRG,4824,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$15,069.03 ",IP,"15,069.03","15,069.03",,,,,,,,,,,,
Meridian Medicaid,DRG,4831,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$5,523.10 ",IP,"5,523.10","5,523.10",,,,,,,,,,,,
Meridian Medicaid,DRG,4832,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$6,593.84 ",IP,"6,593.84","6,593.84",,,,,,,,,,,,
Meridian Medicaid,DRG,4833,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$8,503.71 ",IP,"8,503.71","8,503.71",,,,,,,,,,,,
Meridian Medicaid,DRG,4834,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$16,764.14 ",IP,"16,764.14","16,764.14",,,,,,,,,,,,
Meridian Medicaid,DRG,4841,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,414.47 ",IP,"6,414.47","6,414.47",,,,,,,,,,,,
Meridian Medicaid,DRG,4842,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,,,,,,,
Meridian Medicaid,DRG,4843,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,922.98 ",IP,"7,922.98","7,922.98",,,,,,,,,,,,
Meridian Medicaid,DRG,4844,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$22,148.41 ",IP,"22,148.41","22,148.41",,,,,,,,,,,,
Meridian Medicaid,DRG,5001,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,471.31 ",IP,"3,471.31","3,471.31",,,,,,,,,,,,
Meridian Medicaid,DRG,5002,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,,,,,,,
Meridian Medicaid,DRG,5003,"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",,Relative Weights,"$5,381.18 ",IP,"5,381.18","5,381.18",,,,,,,,,,,,
Meridian Medicaid,DRG,5004,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$8,653.88 ",IP,"8,653.88","8,653.88",,,,,,,,,,,,
Meridian Medicaid,DRG,5011,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,269.65 ",IP,"2,269.65","2,269.65",,,,,,,,,,,,
Meridian Medicaid,DRG,5012,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,988.52 ",IP,"2,988.52","2,988.52",,,,,,,,,,,,
Meridian Medicaid,DRG,5013,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$4,126.95 ",IP,"4,126.95","4,126.95",,,,,,,,,,,,
Meridian Medicaid,DRG,5014,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$8,519.52 ",IP,"8,519.52","8,519.52",,,,,,,,,,,,
Meridian Medicaid,DRG,5101,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$6,667.03 ",IP,"6,667.03","6,667.03",,,,,,,,,,,,
Meridian Medicaid,DRG,5102,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$7,636.06 ",IP,"7,636.06","7,636.06",,,,,,,,,,,,
Meridian Medicaid,DRG,5103,"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",,Relative Weights,"$12,159.55 ",IP,"12,159.55","12,159.55",,,,,,,,,,,,
Meridian Medicaid,DRG,5104,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,,,,,,,
Meridian Medicaid,DRG,5111,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$6,477.69 ",IP,"6,477.69","6,477.69",,,,,,,,,,,,
Meridian Medicaid,DRG,5112,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$7,830.89 ",IP,"7,830.89","7,830.89",,,,,,,,,,,,
Meridian Medicaid,DRG,5113,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$10,746.90 ",IP,"10,746.90","10,746.90",,,,,,,,,,,,
Meridian Medicaid,DRG,5114,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$23,120.88 ",IP,"23,120.88","23,120.88",,,,,,,,,,,,
Meridian Medicaid,DRG,5121,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$6,341.62 ",IP,"6,341.62","6,341.62",,,,,,,,,,,,
Meridian Medicaid,DRG,5122,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,,,,,,,
Meridian Medicaid,DRG,5123,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$9,937.66 ",IP,"9,937.66","9,937.66",,,,,,,,,,,,
Meridian Medicaid,DRG,5124,UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,,Relative Weights,"$20,453.99 ",IP,"20,453.99","20,453.99",,,,,,,,,,,,
Meridian Medicaid,DRG,5131,UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$4,384.67 ",IP,"4,384.67","4,384.67",,,,,,,,,,,,
Meridian Medicaid,DRG,5132,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$5,107.31 ",IP,"5,107.31","5,107.31",,,,,,,,,,,,
Meridian Medicaid,DRG,5133,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$8,107.86 ",IP,"8,107.86","8,107.86",,,,,,,,,,,,
Meridian Medicaid,DRG,5134,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$16,632.53 ",IP,"16,632.53","16,632.53",,,,,,,,,,,,
Meridian Medicaid,DRG,5141,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$3,945.51 ",IP,"3,945.51","3,945.51",,,,,,,,,,,,
Meridian Medicaid,DRG,5142,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$5,893.19 ",IP,"5,893.19","5,893.19",,,,,,,,,,,,
Meridian Medicaid,DRG,5143,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$10,581.96 ",IP,"10,581.96","10,581.96",,,,,,,,,,,,
Meridian Medicaid,DRG,5144,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$22,849.41 ",IP,"22,849.41","22,849.41",,,,,,,,,,,,
Meridian Medicaid,DRG,5171,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$3,258.61 ",IP,"3,258.61","3,258.61",,,,,,,,,,,,
Meridian Medicaid,DRG,5172,DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,,Relative Weights,"$4,494.28 ",IP,"4,494.28","4,494.28",,,,,,,,,,,,
Meridian Medicaid,DRG,5173,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$6,942.62 ",IP,"6,942.62","6,942.62",,,,,,,,,,,,
Meridian Medicaid,DRG,5174,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$14,767.33 ",IP,"14,767.33","14,767.33",,,,,,,,,,,,
Meridian Medicaid,DRG,5181,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$4,123.51 ",IP,"4,123.51","4,123.51",,,,,,,,,,,,
Meridian Medicaid,DRG,5182,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$5,436.16 ",IP,"5,436.16","5,436.16",,,,,,,,,,,,
Meridian Medicaid,DRG,5183,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$9,420.16 ",IP,"9,420.16","9,420.16",,,,,,,,,,,,
Meridian Medicaid,DRG,5184,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$21,115.47 ",IP,"21,115.47","21,115.47",,,,,,,,,,,,
Meridian Medicaid,DRG,5191,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,160.33 ",IP,"3,160.33","3,160.33",,,,,,,,,,,,
Meridian Medicaid,DRG,5192,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,849.30 ",IP,"3,849.30","3,849.30",,,,,,,,,,,,
Meridian Medicaid,DRG,5193,UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,,,,,,,
Meridian Medicaid,DRG,5194,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$15,622.96 ",IP,"15,622.96","15,622.96",,,,,,,,,,,,
Meridian Medicaid,DRG,5301,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,382.31 ",IP,"3,382.31","3,382.31",,,,,,,,,,,,
Meridian Medicaid,DRG,5302,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,815.97 ",IP,"3,815.97","3,815.97",,,,,,,,,,,,
Meridian Medicaid,DRG,5303,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$5,327.23 ",IP,"5,327.23","5,327.23",,,,,,,,,,,,
Meridian Medicaid,DRG,5304,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$9,039.08 ",IP,"9,039.08","9,039.08",,,,,,,,,,,,
Meridian Medicaid,DRG,5311,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,096.46 ",IP,"2,096.46","2,096.46",,,,,,,,,,,,
Meridian Medicaid,DRG,5312,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,868.93 ",IP,"2,868.93","2,868.93",,,,,,,,,,,,
Meridian Medicaid,DRG,5313,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$4,503.56 ",IP,"4,503.56","4,503.56",,,,,,,,,,,,
Meridian Medicaid,DRG,5314,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$9,958.97 ",IP,"9,958.97","9,958.97",,,,,,,,,,,,
Meridian Medicaid,DRG,5321,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,302.29 ",IP,"2,302.29","2,302.29",,,,,,,,,,,,
Meridian Medicaid,DRG,5322,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,696.78 ",IP,"2,696.78","2,696.78",,,,,,,,,,,,
Meridian Medicaid,DRG,5323,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$4,143.44 ",IP,"4,143.44","4,143.44",,,,,,,,,,,,
Meridian Medicaid,DRG,5324,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$9,044.24 ",IP,"9,044.24","9,044.24",,,,,,,,,,,,
Meridian Medicaid,DRG,5401,CESAREAN DELIVERY,,Relative Weights,"$2,493.69 ",IP,"2,493.69","2,493.69",,,,,,,,,,,,
Meridian Medicaid,DRG,5402,CESAREAN DELIVERY,,Relative Weights,"$2,909.48 ",IP,"2,909.48","2,909.48",,,,,,,,,,,,
Meridian Medicaid,DRG,5403,CESAREAN DELIVERY,,Relative Weights,"$4,140.35 ",IP,"4,140.35","4,140.35",,,,,,,,,,,,
Meridian Medicaid,DRG,5404,CESAREAN DELIVERY,,Relative Weights,"$8,525.02 ",IP,"8,525.02","8,525.02",,,,,,,,,,,,
Meridian Medicaid,DRG,5411,VAGINAL DELIVERY W STERILIZATION &/OR D&C,,Relative Weights,"$2,683.03 ",IP,"2,683.03","2,683.03",,,,,,,,,,,,
Meridian Medicaid,DRG,5412,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$2,694.03 ",IP,"2,694.03","2,694.03",,,,,,,,,,,,
Meridian Medicaid,DRG,5413,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$3,800.85 ",IP,"3,800.85","3,800.85",,,,,,,,,,,,
Meridian Medicaid,DRG,5414,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$9,356.59 ",IP,"9,356.59","9,356.59",,,,,,,,,,,,
Meridian Medicaid,DRG,5421,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,,Relative Weights,"$1,729.81 ",IP,"1,729.81","1,729.81",,,,,,,,,,,,
Meridian Medicaid,DRG,5422,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$1,962.10 ",IP,"1,962.10","1,962.10",,,,,,,,,,,,
Meridian Medicaid,DRG,5423,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$2,979.24 ",IP,"2,979.24","2,979.24",,,,,,,,,,,,
Meridian Medicaid,DRG,5424,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$11,346.53 ",IP,"11,346.53","11,346.53",,,,,,,,,,,,
Meridian Medicaid,DRG,5441,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$1,946.30 ",IP,"1,946.30","1,946.30",,,,,,,,,,,,
Meridian Medicaid,DRG,5442,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$2,595.06 ",IP,"2,595.06","2,595.06",,,,,,,,,,,,
Meridian Medicaid,DRG,5443,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$3,856.51 ",IP,"3,856.51","3,856.51",,,,,,,,,,,,
Meridian Medicaid,DRG,5444,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$14,310.30 ",IP,"14,310.30","14,310.30",,,,,,,,,,,,
Meridian Medicaid,DRG,5451,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$2,785.09 ",IP,"2,785.09","2,785.09",,,,,,,,,,,,
Meridian Medicaid,DRG,5452,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,114.63 ",IP,"3,114.63","3,114.63",,,,,,,,,,,,
Meridian Medicaid,DRG,5453,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,214.96 ",IP,"3,214.96","3,214.96",,,,,,,,,,,,
Meridian Medicaid,DRG,5454,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$4,812.48 ",IP,"4,812.48","4,812.48",,,,,,,,,,,,
Meridian Medicaid,DRG,5461,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$2,385.45 ",IP,"2,385.45","2,385.45",,,,,,,,,,,,
Meridian Medicaid,DRG,5462,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$4,587.41 ",IP,"4,587.41","4,587.41",,,,,,,,,,,,
Meridian Medicaid,DRG,5463,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$5,857.79 ",IP,"5,857.79","5,857.79",,,,,,,,,,,,
Meridian Medicaid,DRG,5464,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$11,895.30 ",IP,"11,895.30","11,895.30",,,,,,,,,,,,
Meridian Medicaid,DRG,5601,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,539.10 ",IP,"1,539.10","1,539.10",,,,,,,,,,,,
Meridian Medicaid,DRG,5602,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,659.37 ",IP,"1,659.37","1,659.37",,,,,,,,,,,,
Meridian Medicaid,DRG,5603,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$2,337.34 ",IP,"2,337.34","2,337.34",,,,,,,,,,,,
Meridian Medicaid,DRG,5604,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$4,292.23 ",IP,"4,292.23","4,292.23",,,,,,,,,,,,
Meridian Medicaid,DRG,5611,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,236.71 ",IP,"1,236.71","1,236.71",,,,,,,,,,,,
Meridian Medicaid,DRG,5612,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,778.26 ",IP,"1,778.26","1,778.26",,,,,,,,,,,,
Meridian Medicaid,DRG,5613,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$2,747.29 ",IP,"2,747.29","2,747.29",,,,,,,,,,,,
Meridian Medicaid,DRG,5614,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$5,898.34 ",IP,"5,898.34","5,898.34",,,,,,,,,,,,
Meridian Medicaid,DRG,5631,PRETERM LABOR,,Relative Weights,"$1,387.56 ",IP,"1,387.56","1,387.56",,,,,,,,,,,,
Meridian Medicaid,DRG,5632,PRETERM LABOR,,Relative Weights,"$1,719.85 ",IP,"1,719.85","1,719.85",,,,,,,,,,,,
Meridian Medicaid,DRG,5633,PRETERM LABOR,,Relative Weights,"$2,634.92 ",IP,"2,634.92","2,634.92",,,,,,,,,,,,
Meridian Medicaid,DRG,5634,PRETERM LABOR,,Relative Weights,"$4,637.23 ",IP,"4,637.23","4,637.23",,,,,,,,,,,,
Meridian Medicaid,DRG,5641,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$1,463.85 ",IP,"1,463.85","1,463.85",,,,,,,,,,,,
Meridian Medicaid,DRG,5642,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$1,520.55 ",IP,"1,520.55","1,520.55",,,,,,,,,,,,
Meridian Medicaid,DRG,5643,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$2,435.62 ",IP,"2,435.62","2,435.62",,,,,,,,,,,,
Meridian Medicaid,DRG,5644,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$3,935.55 ",IP,"3,935.55","3,935.55",,,,,,,,,,,,
Meridian Medicaid,DRG,5651,FALSE LABOR,FALSE LABOR,Relative Weights,$992.39 ,IP,992.39,992.39,,,,,,,,,,,,
Meridian Medicaid,DRG,5652,FALSE LABOR,FALSE LABOR,Relative Weights,"$1,254.23 ",IP,"1,254.23","1,254.23",,,,,,,,,,,,
Meridian Medicaid,DRG,5653,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,,,,,,,
Meridian Medicaid,DRG,5654,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,,,,,,,
Meridian Medicaid,DRG,5661,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,462.82 ",IP,"1,462.82","1,462.82",,,,,,,,,,,,
Meridian Medicaid,DRG,5662,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,906.44 ",IP,"1,906.44","1,906.44",,,,,,,,,,,,
Meridian Medicaid,DRG,5663,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$2,718.08 ",IP,"2,718.08","2,718.08",,,,,,,,,,,,
Meridian Medicaid,DRG,5664,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$5,715.19 ",IP,"5,715.19","5,715.19",,,,,,,,,,,,
Meridian Medicaid,DRG,5801,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$1,625.35 ",IP,"1,625.35","1,625.35",,,,,,,,,,,,
Meridian Medicaid,DRG,5802,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$2,301.61 ",IP,"2,301.61","2,301.61",,,,,,,,,,,,
Meridian Medicaid,DRG,5803,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$3,477.84 ",IP,"3,477.84","3,477.84",,,,,,,,,,,,
Meridian Medicaid,DRG,5804,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,,,,,,,
Meridian Medicaid,DRG,5811,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,$559.42 ,IP,559.42,559.42,,,,,,,,,,,,
Meridian Medicaid,DRG,5812,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,$716.80 ,IP,716.8,716.8,,,,,,,,,,,,
Meridian Medicaid,DRG,5813,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,"$1,204.41 ",IP,"1,204.41","1,204.41",,,,,,,,,,,,
Meridian Medicaid,DRG,5814,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,"$2,109.52 ",IP,"2,109.52","2,109.52",,,,,,,,,,,,
Meridian Medicaid,DRG,5831,NEONATE W ECMO,,Relative Weights,"$87,271.04 ",IP,"87,271.04","87,271.04",,,,,,,,,,,,
Meridian Medicaid,DRG,5832,NEONATE W ECMO,,Relative Weights,"$87,459.00 ",IP,"87,459.00","87,459.00",,,,,,,,,,,,
Meridian Medicaid,DRG,5833,NEONATE W ECMO,,Relative Weights,"$148,358.12 ",IP,"148,358.12","148,358.12",,,,,,,,,,,,
Meridian Medicaid,DRG,5834,NEONATE W ECMO,,Relative Weights,"$163,193.83 ",IP,"163,193.83","163,193.83",,,,,,,,,,,,
Meridian Medicaid,DRG,5881,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$67,852.39 ",IP,"67,852.39","67,852.39",,,,,,,,,,,,
Meridian Medicaid,DRG,5882,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$75,391.54 ",IP,"75,391.54","75,391.54",,,,,,,,,,,,
Meridian Medicaid,DRG,5883,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$83,636.16 ",IP,"83,636.16","83,636.16",,,,,,,,,,,,
Meridian Medicaid,DRG,5884,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$133,619.66 ",IP,"133,619.66","133,619.66",,,,,,,,,,,,
Meridian Medicaid,DRG,5891,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$98,896.59 ",IP,"98,896.59","98,896.59",,,,,,,,,,,,
Meridian Medicaid,DRG,5892,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$69,370.87 ",IP,"69,370.87","69,370.87",,,,,,,,,,,,
Meridian Medicaid,DRG,5893,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$63,064.65 ",IP,"63,064.65","63,064.65",,,,,,,,,,,,
Meridian Medicaid,DRG,5894,NEONATE BWT <500G OR GA <24 WEEKS,,Relative Weights,"$11,889.12 ",IP,"11,889.12","11,889.12",,,,,,,,,,,,
Meridian Medicaid,DRG,5911,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$57,344.65 ",IP,"57,344.65","57,344.65",,,,,,,,,,,,
Meridian Medicaid,DRG,5912,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$79,559.04 ",IP,"79,559.04","79,559.04",,,,,,,,,,,,
Meridian Medicaid,DRG,5913,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$85,488.65 ",IP,"85,488.65","85,488.65",,,,,,,,,,,,
Meridian Medicaid,DRG,5914,NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,,Relative Weights,"$110,417.00 ",IP,"110,417.00","110,417.00",,,,,,,,,,,,
Meridian Medicaid,DRG,5931,NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,,Relative Weights,"$37,781.34 ",IP,"37,781.34","37,781.34",,,,,,,,,,,,
Meridian Medicaid,DRG,5932,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$59,330.12 ",IP,"59,330.12","59,330.12",,,,,,,,,,,,
Meridian Medicaid,DRG,5933,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$71,323.01 ",IP,"71,323.01","71,323.01",,,,,,,,,,,,
Meridian Medicaid,DRG,5934,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$96,423.52 ",IP,"96,423.52","96,423.52",,,,,,,,,,,,
Meridian Medicaid,DRG,6021,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$36,367.31 ",IP,"36,367.31","36,367.31",,,,,,,,,,,,
Meridian Medicaid,DRG,6022,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$43,081.42 ",IP,"43,081.42","43,081.42",,,,,,,,,,,,
Meridian Medicaid,DRG,6023,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$56,708.94 ",IP,"56,708.94","56,708.94",,,,,,,,,,,,
Meridian Medicaid,DRG,6024,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$82,218.02 ",IP,"82,218.02","82,218.02",,,,,,,,,,,,
Meridian Medicaid,DRG,6031,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$21,131.62 ",IP,"21,131.62","21,131.62",,,,,,,,,,,,
Meridian Medicaid,DRG,6032,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$31,760.66 ",IP,"31,760.66","31,760.66",,,,,,,,,,,,
Meridian Medicaid,DRG,6033,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,733.18 ",IP,"45,733.18","45,733.18",,,,,,,,,,,,
Meridian Medicaid,DRG,6034,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$71,521.63 ",IP,"71,521.63","71,521.63",,,,,,,,,,,,
Meridian Medicaid,DRG,6071,NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$24,973.02 ",IP,"24,973.02","24,973.02",,,,,,,,,,,,
Meridian Medicaid,DRG,6072,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$31,699.15 ",IP,"31,699.15","31,699.15",,,,,,,,,,,,
Meridian Medicaid,DRG,6073,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$41,632.01 ",IP,"41,632.01","41,632.01",,,,,,,,,,,,
Meridian Medicaid,DRG,6074,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$64,492.07 ",IP,"64,492.07","64,492.07",,,,,,,,,,,,
Meridian Medicaid,DRG,6081,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$16,607.44 ",IP,"16,607.44","16,607.44",,,,,,,,,,,,
Meridian Medicaid,DRG,6082,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$23,967.23 ",IP,"23,967.23","23,967.23",,,,,,,,,,,,
Meridian Medicaid,DRG,6083,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$34,646.09 ",IP,"34,646.09","34,646.09",,,,,,,,,,,,
Meridian Medicaid,DRG,6084,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$60,788.81 ",IP,"60,788.81","60,788.81",,,,,,,,,,,,
Meridian Medicaid,DRG,6091,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$25,499.11 ",IP,"25,499.11","25,499.11",,,,,,,,,,,,
Meridian Medicaid,DRG,6092,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$27,431.32 ",IP,"27,431.32","27,431.32",,,,,,,,,,,,
Meridian Medicaid,DRG,6093,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$47,002.54 ",IP,"47,002.54","47,002.54",,,,,,,,,,,,
Meridian Medicaid,DRG,6094,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$99,687.62 ",IP,"99,687.62","99,687.62",,,,,,,,,,,,
Meridian Medicaid,DRG,6111,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$12,585.30 ",IP,"12,585.30","12,585.30",,,,,,,,,,,,
Meridian Medicaid,DRG,6112,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$19,393.91 ",IP,"19,393.91","19,393.91",,,,,,,,,,,,
Meridian Medicaid,DRG,6113,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$32,347.92 ",IP,"32,347.92","32,347.92",,,,,,,,,,,,
Meridian Medicaid,DRG,6114,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$58,174.51 ",IP,"58,174.51","58,174.51",,,,,,,,,,,,
Meridian Medicaid,DRG,6121,NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,,Relative Weights,"$16,224.65 ",IP,"16,224.65","16,224.65",,,,,,,,,,,,
Meridian Medicaid,DRG,6122,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$21,637.79 ",IP,"21,637.79","21,637.79",,,,,,,,,,,,
Meridian Medicaid,DRG,6123,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$29,186.22 ",IP,"29,186.22","29,186.22",,,,,,,,,,,,
Meridian Medicaid,DRG,6124,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$42,407.23 ",IP,"42,407.23","42,407.23",,,,,,,,,,,,
Meridian Medicaid,DRG,6131,NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,196.61 ",IP,"13,196.61","13,196.61",,,,,,,,,,,,
Meridian Medicaid,DRG,6132,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$21,189.35 ",IP,"21,189.35","21,189.35",,,,,,,,,,,,
Meridian Medicaid,DRG,6133,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$27,656.40 ",IP,"27,656.40","27,656.40",,,,,,,,,,,,
Meridian Medicaid,DRG,6134,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$47,731.03 ",IP,"47,731.03","47,731.03",,,,,,,,,,,,
Meridian Medicaid,DRG,6141,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,925.34 ",IP,"8,925.34","8,925.34",,,,,,,,,,,,
Meridian Medicaid,DRG,6142,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$15,030.54 ",IP,"15,030.54","15,030.54",,,,,,,,,,,,
Meridian Medicaid,DRG,6143,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,580.55 ",IP,"25,580.55","25,580.55",,,,,,,,,,,,
Meridian Medicaid,DRG,6144,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,341.79 ",IP,"45,341.79","45,341.79",,,,,,,,,,,,
Meridian Medicaid,DRG,6211,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$6,929.91 ",IP,"6,929.91","6,929.91",,,,,,,,,,,,
Meridian Medicaid,DRG,6212,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$14,367.69 ",IP,"14,367.69","14,367.69",,,,,,,,,,,,
Meridian Medicaid,DRG,6213,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$26,320.72 ",IP,"26,320.72","26,320.72",,,,,,,,,,,,
Meridian Medicaid,DRG,6214,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$49,514.79 ",IP,"49,514.79","49,514.79",,,,,,,,,,,,
Meridian Medicaid,DRG,6221,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$10,129.06 ",IP,"10,129.06","10,129.06",,,,,,,,,,,,
Meridian Medicaid,DRG,6222,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$13,681.47 ",IP,"13,681.47","13,681.47",,,,,,,,,,,,
Meridian Medicaid,DRG,6223,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$17,417.03 ",IP,"17,417.03","17,417.03",,,,,,,,,,,,
Meridian Medicaid,DRG,6224,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$32,501.52 ",IP,"32,501.52","32,501.52",,,,,,,,,,,,
Meridian Medicaid,DRG,6231,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$7,947.73 ",IP,"7,947.73","7,947.73",,,,,,,,,,,,
Meridian Medicaid,DRG,6232,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$11,704.59 ",IP,"11,704.59","11,704.59",,,,,,,,,,,,
Meridian Medicaid,DRG,6233,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$18,604.26 ",IP,"18,604.26","18,604.26",,,,,,,,,,,,
Meridian Medicaid,DRG,6234,NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$29,470.40 ",IP,"29,470.40","29,470.40",,,,,,,,,,,,
Meridian Medicaid,DRG,6251,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,481.72 ",IP,"8,481.72","8,481.72",,,,,,,,,,,,
Meridian Medicaid,DRG,6252,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$12,056.81 ",IP,"12,056.81","12,056.81",,,,,,,,,,,,
Meridian Medicaid,DRG,6253,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$17,253.12 ",IP,"17,253.12","17,253.12",,,,,,,,,,,,
Meridian Medicaid,DRG,6254,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,500.83 ",IP,"25,500.83","25,500.83",,,,,,,,,,,,
Meridian Medicaid,DRG,6261,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,026.75 ",IP,"1,026.75","1,026.75",,,,,,,,,,,,
Meridian Medicaid,DRG,6262,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,832.56 ",IP,"1,832.56","1,832.56",,,,,,,,,,,,
Meridian Medicaid,DRG,6263,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$5,129.99 ",IP,"5,129.99","5,129.99",,,,,,,,,,,,
Meridian Medicaid,DRG,6264,"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$14,511.67 ",IP,"14,511.67","14,511.67",,,,,,,,,,,,
Meridian Medicaid,DRG,6301,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$14,642.59 ",IP,"14,642.59","14,642.59",,,,,,,,,,,,
Meridian Medicaid,DRG,6302,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$26,499.41 ",IP,"26,499.41","26,499.41",,,,,,,,,,,,
Meridian Medicaid,DRG,6303,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$44,508.84 ",IP,"44,508.84","44,508.84",,,,,,,,,,,,
Meridian Medicaid,DRG,6304,NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$79,154.59 ",IP,"79,154.59","79,154.59",,,,,,,,,,,,
Meridian Medicaid,DRG,6311,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$11,884.65 ",IP,"11,884.65","11,884.65",,,,,,,,,,,,
Meridian Medicaid,DRG,6312,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$19,077.77 ",IP,"19,077.77","19,077.77",,,,,,,,,,,,
Meridian Medicaid,DRG,6313,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$33,764.00 ",IP,"33,764.00","33,764.00",,,,,,,,,,,,
Meridian Medicaid,DRG,6314,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$74,464.79 ",IP,"74,464.79","74,464.79",,,,,,,,,,,,
Meridian Medicaid,DRG,6331,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$2,688.87 ",IP,"2,688.87","2,688.87",,,,,,,,,,,,
Meridian Medicaid,DRG,6332,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$7,851.51 ",IP,"7,851.51","7,851.51",,,,,,,,,,,,
Meridian Medicaid,DRG,6333,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$17,713.92 ",IP,"17,713.92","17,713.92",,,,,,,,,,,,
Meridian Medicaid,DRG,6334,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$44,843.19 ",IP,"44,843.19","44,843.19",,,,,,,,,,,,
Meridian Medicaid,DRG,6341,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$4,461.64 ",IP,"4,461.64","4,461.64",,,,,,,,,,,,
Meridian Medicaid,DRG,6342,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$7,881.41 ",IP,"7,881.41","7,881.41",,,,,,,,,,,,
Meridian Medicaid,DRG,6343,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$11,444.81 ",IP,"11,444.81","11,444.81",,,,,,,,,,,,
Meridian Medicaid,DRG,6344,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$28,806.17 ",IP,"28,806.17","28,806.17",,,,,,,,,,,,
Meridian Medicaid,DRG,6361,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$4,375.39 ",IP,"4,375.39","4,375.39",,,,,,,,,,,,
Meridian Medicaid,DRG,6362,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$6,615.83 ",IP,"6,615.83","6,615.83",,,,,,,,,,,,
Meridian Medicaid,DRG,6363,NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,140.60 ",IP,"13,140.60","13,140.60",,,,,,,,,,,,
Meridian Medicaid,DRG,6364,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$22,289.30 ",IP,"22,289.30","22,289.30",,,,,,,,,,,,
Meridian Medicaid,DRG,6391,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$4,122.14 ",IP,"4,122.14","4,122.14",,,,,,,,,,,,
Meridian Medicaid,DRG,6392,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$7,440.19 ",IP,"7,440.19","7,440.19",,,,,,,,,,,,
Meridian Medicaid,DRG,6393,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$11,681.22 ",IP,"11,681.22","11,681.22",,,,,,,,,,,,
Meridian Medicaid,DRG,6394,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$20,735.08 ",IP,"20,735.08","20,735.08",,,,,,,,,,,,
Meridian Medicaid,DRG,6401,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$571.11 ,IP,571.11,571.11,,,,,,,,,,,,
Meridian Medicaid,DRG,6402,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$900.64 ,IP,900.64,900.64,,,,,,,,,,,,
Meridian Medicaid,DRG,6403,"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$2,228.41 ",IP,"2,228.41","2,228.41",,,,,,,,,,,,
Meridian Medicaid,DRG,6404,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$13,890.74 ",IP,"13,890.74","13,890.74",,,,,,,,,,,,
Meridian Medicaid,DRG,6501,SPLENECTOMY,,Relative Weights,"$6,304.16 ",IP,"6,304.16","6,304.16",,,,,,,,,,,,
Meridian Medicaid,DRG,6502,SPLENECTOMY,,Relative Weights,"$8,491.69 ",IP,"8,491.69","8,491.69",,,,,,,,,,,,
Meridian Medicaid,DRG,6503,SPLENECTOMY,,Relative Weights,"$13,332.00 ",IP,"13,332.00","13,332.00",,,,,,,,,,,,
Meridian Medicaid,DRG,6504,SPLENECTOMY,,Relative Weights,"$23,483.06 ",IP,"23,483.06","23,483.06",,,,,,,,,,,,
Meridian Medicaid,DRG,6511,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,,,,,,,
Meridian Medicaid,DRG,6512,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$7,236.76 ",IP,"7,236.76","7,236.76",,,,,,,,,,,,
Meridian Medicaid,DRG,6513,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$10,916.31 ",IP,"10,916.31","10,916.31",,,,,,,,,,,,
Meridian Medicaid,DRG,6514,OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,,Relative Weights,"$33,538.24 ",IP,"33,538.24","33,538.24",,,,,,,,,,,,
Meridian Medicaid,DRG,6601,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$3,747.59 ",IP,"3,747.59","3,747.59",,,,,,,,,,,,
Meridian Medicaid,DRG,6602,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$4,287.77 ",IP,"4,287.77","4,287.77",,,,,,,,,,,,
Meridian Medicaid,DRG,6603,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$6,366.70 ",IP,"6,366.70","6,366.70",,,,,,,,,,,,
Meridian Medicaid,DRG,6604,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$16,194.41 ",IP,"16,194.41","16,194.41",,,,,,,,,,,,
Meridian Medicaid,DRG,6611,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$3,902.56 ",IP,"3,902.56","3,902.56",,,,,,,,,,,,
Meridian Medicaid,DRG,6612,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$5,668.11 ",IP,"5,668.11","5,668.11",,,,,,,,,,,,
Meridian Medicaid,DRG,6613,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$9,739.74 ",IP,"9,739.74","9,739.74",,,,,,,,,,,,
Meridian Medicaid,DRG,6614,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$15,545.30 ",IP,"15,545.30","15,545.30",,,,,,,,,,,,
Meridian Medicaid,DRG,6621,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$2,821.17 ",IP,"2,821.17","2,821.17",,,,,,,,,,,,
Meridian Medicaid,DRG,6622,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$3,681.27 ",IP,"3,681.27","3,681.27",,,,,,,,,,,,
Meridian Medicaid,DRG,6623,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$5,206.96 ",IP,"5,206.96","5,206.96",,,,,,,,,,,,
Meridian Medicaid,DRG,6624,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$10,694.33 ",IP,"10,694.33","10,694.33",,,,,,,,,,,,
Meridian Medicaid,DRG,6631,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$2,701.59 ",IP,"2,701.59","2,701.59",,,,,,,,,,,,
Meridian Medicaid,DRG,6632,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$3,327.33 ",IP,"3,327.33","3,327.33",,,,,,,,,,,,
Meridian Medicaid,DRG,6633,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$4,391.20 ",IP,"4,391.20","4,391.20",,,,,,,,,,,,
Meridian Medicaid,DRG,6634,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$8,007.52 ",IP,"8,007.52","8,007.52",,,,,,,,,,,,
Meridian Medicaid,DRG,6801,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,740.52 ",IP,"7,740.52","7,740.52",,,,,,,,,,,,
Meridian Medicaid,DRG,6802,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$10,236.62 ",IP,"10,236.62","10,236.62",,,,,,,,,,,,
Meridian Medicaid,DRG,6803,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$16,199.56 ",IP,"16,199.56","16,199.56",,,,,,,,,,,,
Meridian Medicaid,DRG,6804,MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,,Relative Weights,"$34,974.94 ",IP,"34,974.94","34,974.94",,,,,,,,,,,,
Meridian Medicaid,DRG,6811,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$6,220.66 ",IP,"6,220.66","6,220.66",,,,,,,,,,,,
Meridian Medicaid,DRG,6812,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,805.46 ",IP,"7,805.46","7,805.46",,,,,,,,,,,,
Meridian Medicaid,DRG,6813,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$13,731.30 ",IP,"13,731.30","13,731.30",,,,,,,,,,,,
Meridian Medicaid,DRG,6814,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$32,311.50 ",IP,"32,311.50","32,311.50",,,,,,,,,,,,
Meridian Medicaid,DRG,6901,ACUTE LEUKEMIA,,Relative Weights,"$8,376.23 ",IP,"8,376.23","8,376.23",,,,,,,,,,,,
Meridian Medicaid,DRG,6902,ACUTE LEUKEMIA,,Relative Weights,"$11,965.06 ",IP,"11,965.06","11,965.06",,,,,,,,,,,,
Meridian Medicaid,DRG,6903,ACUTE LEUKEMIA,,Relative Weights,"$18,264.07 ",IP,"18,264.07","18,264.07",,,,,,,,,,,,
Meridian Medicaid,DRG,6904,ACUTE LEUKEMIA,,Relative Weights,"$33,495.63 ",IP,"33,495.63","33,495.63",,,,,,,,,,,,
Meridian Medicaid,DRG,6911,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$6,184.92 ",IP,"6,184.92","6,184.92",,,,,,,,,,,,
Meridian Medicaid,DRG,6912,"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",,Relative Weights,"$6,251.93 ",IP,"6,251.93","6,251.93",,,,,,,,,,,,
Meridian Medicaid,DRG,6913,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$9,090.97 ",IP,"9,090.97","9,090.97",,,,,,,,,,,,
Meridian Medicaid,DRG,6914,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$18,806.65 ",IP,"18,806.65","18,806.65",,,,,,,,,,,,
Meridian Medicaid,DRG,6921,RADIOTHERAPY,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,,,,,,,
Meridian Medicaid,DRG,6922,RADIOTHERAPY,,Relative Weights,"$8,603.36 ",IP,"8,603.36","8,603.36",,,,,,,,,,,,
Meridian Medicaid,DRG,6923,RADIOTHERAPY,,Relative Weights,"$11,232.45 ",IP,"11,232.45","11,232.45",,,,,,,,,,,,
Meridian Medicaid,DRG,6924,RADIOTHERAPY,,Relative Weights,"$22,232.95 ",IP,"22,232.95","22,232.95",,,,,,,,,,,,
Meridian Medicaid,DRG,6941,LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$3,669.93 ",IP,"3,669.93","3,669.93",,,,,,,,,,,,
Meridian Medicaid,DRG,6942,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$4,230.04 ",IP,"4,230.04","4,230.04",,,,,,,,,,,,
Meridian Medicaid,DRG,6943,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$5,867.41 ",IP,"5,867.41","5,867.41",,,,,,,,,,,,
Meridian Medicaid,DRG,6944,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$11,092.25 ",IP,"11,092.25","11,092.25",,,,,,,,,,,,
Meridian Medicaid,DRG,6951,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$3,844.14 ",IP,"3,844.14","3,844.14",,,,,,,,,,,,
Meridian Medicaid,DRG,6952,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$4,908.70 ",IP,"4,908.70","4,908.70",,,,,,,,,,,,
Meridian Medicaid,DRG,6953,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$11,375.74 ",IP,"11,375.74","11,375.74",,,,,,,,,,,,
Meridian Medicaid,DRG,6954,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$32,868.17 ",IP,"32,868.17","32,868.17",,,,,,,,,,,,
Meridian Medicaid,DRG,6961,OTHER CHEMOTHERAPY,,Relative Weights,"$4,174.03 ",IP,"4,174.03","4,174.03",,,,,,,,,,,,
Meridian Medicaid,DRG,6962,OTHER CHEMOTHERAPY,,Relative Weights,"$5,397.68 ",IP,"5,397.68","5,397.68",,,,,,,,,,,,
Meridian Medicaid,DRG,6963,OTHER CHEMOTHERAPY,,Relative Weights,"$7,757.01 ",IP,"7,757.01","7,757.01",,,,,,,,,,,,
Meridian Medicaid,DRG,6964,OTHER CHEMOTHERAPY,,Relative Weights,"$17,845.53 ",IP,"17,845.53","17,845.53",,,,,,,,,,,,
Meridian Medicaid,DRG,7101,INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,,Relative Weights,"$5,318.64 ",IP,"5,318.64","5,318.64",,,,,,,,,,,,
Meridian Medicaid,DRG,7102,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$7,922.30 ",IP,"7,922.30","7,922.30",,,,,,,,,,,,
Meridian Medicaid,DRG,7103,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$12,117.63 ",IP,"12,117.63","12,117.63",,,,,,,,,,,,
Meridian Medicaid,DRG,7104,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$24,582.32 ",IP,"24,582.32","24,582.32",,,,,,,,,,,,
Meridian Medicaid,DRG,7111,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$5,432.73 ",IP,"5,432.73","5,432.73",,,,,,,,,,,,
Meridian Medicaid,DRG,7112,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$7,124.05 ",IP,"7,124.05","7,124.05",,,,,,,,,,,,
Meridian Medicaid,DRG,7113,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$12,166.42 ",IP,"12,166.42","12,166.42",,,,,,,,,,,,
Meridian Medicaid,DRG,7114,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$25,010.82 ",IP,"25,010.82","25,010.82",,,,,,,,,,,,
Meridian Medicaid,DRG,7201,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$2,801.24 ",IP,"2,801.24","2,801.24",,,,,,,,,,,,
Meridian Medicaid,DRG,7202,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$3,678.52 ",IP,"3,678.52","3,678.52",,,,,,,,,,,,
Meridian Medicaid,DRG,7203,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$5,399.74 ",IP,"5,399.74","5,399.74",,,,,,,,,,,,
Meridian Medicaid,DRG,7204,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$10,740.72 ",IP,"10,740.72","10,740.72",,,,,,,,,,,,
Meridian Medicaid,DRG,7211,"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",,Relative Weights,"$2,917.38 ",IP,"2,917.38","2,917.38",,,,,,,,,,,,
Meridian Medicaid,DRG,7212,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$3,837.27 ",IP,"3,837.27","3,837.27",,,,,,,,,,,,
Meridian Medicaid,DRG,7213,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$6,182.18 ",IP,"6,182.18","6,182.18",,,,,,,,,,,,
Meridian Medicaid,DRG,7214,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$12,158.86 ",IP,"12,158.86","12,158.86",,,,,,,,,,,,
Meridian Medicaid,DRG,7221,FEVER,,Relative Weights,"$1,952.14 ",IP,"1,952.14","1,952.14",,,,,,,,,,,,
Meridian Medicaid,DRG,7222,FEVER,,Relative Weights,"$2,920.13 ",IP,"2,920.13","2,920.13",,,,,,,,,,,,
Meridian Medicaid,DRG,7223,FEVER,,Relative Weights,"$3,952.39 ",IP,"3,952.39","3,952.39",,,,,,,,,,,,
Meridian Medicaid,DRG,7224,FEVER,,Relative Weights,"$6,941.25 ",IP,"6,941.25","6,941.25",,,,,,,,,,,,
Meridian Medicaid,DRG,7231,VIRAL ILLNESS,,Relative Weights,"$1,908.50 ",IP,"1,908.50","1,908.50",,,,,,,,,,,,
Meridian Medicaid,DRG,7232,VIRAL ILLNESS,,Relative Weights,"$2,685.44 ",IP,"2,685.44","2,685.44",,,,,,,,,,,,
Meridian Medicaid,DRG,7233,VIRAL ILLNESS,,Relative Weights,"$4,131.07 ",IP,"4,131.07","4,131.07",,,,,,,,,,,,
Meridian Medicaid,DRG,7234,VIRAL ILLNESS,,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,,,,,,,
Meridian Medicaid,DRG,7241,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,048.31 ",IP,"3,048.31","3,048.31",,,,,,,,,,,,
Meridian Medicaid,DRG,7242,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,655.49 ",IP,"3,655.49","3,655.49",,,,,,,,,,,,
Meridian Medicaid,DRG,7243,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$5,820.68 ",IP,"5,820.68","5,820.68",,,,,,,,,,,,
Meridian Medicaid,DRG,7244,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$13,099.02 ",IP,"13,099.02","13,099.02",,,,,,,,,,,,
Meridian Medicaid,DRG,7401,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,032.70 ",IP,"6,032.70","6,032.70",,,,,,,,,,,,
Meridian Medicaid,DRG,7402,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,703.46 ",IP,"6,703.46","6,703.46",,,,,,,,,,,,
Meridian Medicaid,DRG,7403,MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,,Relative Weights,"$13,324.79 ",IP,"13,324.79","13,324.79",,,,,,,,,,,,
Meridian Medicaid,DRG,7404,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$26,668.81 ",IP,"26,668.81","26,668.81",,,,,,,,,,,,
Meridian Medicaid,DRG,7501,SCHIZOPHRENIA,,Relative Weights,"$2,530.12 ",IP,"2,530.12","2,530.12",,,,,,,,,,,,
Meridian Medicaid,DRG,7502,SCHIZOPHRENIA,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,,,,,,,
Meridian Medicaid,DRG,7503,SCHIZOPHRENIA,,Relative Weights,"$4,799.08 ",IP,"4,799.08","4,799.08",,,,,,,,,,,,
Meridian Medicaid,DRG,7504,SCHIZOPHRENIA,,Relative Weights,"$13,473.58 ",IP,"13,473.58","13,473.58",,,,,,,,,,,,
Meridian Medicaid,DRG,7511,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$1,760.40 ",IP,"1,760.40","1,760.40",,,,,,,,,,,,
Meridian Medicaid,DRG,7512,MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,,Relative Weights,"$2,237.01 ",IP,"2,237.01","2,237.01",,,,,,,,,,,,
Meridian Medicaid,DRG,7513,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$3,773.70 ",IP,"3,773.70","3,773.70",,,,,,,,,,,,
Meridian Medicaid,DRG,7514,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$8,518.14 ",IP,"8,518.14","8,518.14",,,,,,,,,,,,
Meridian Medicaid,DRG,7521,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$1,687.20 ",IP,"1,687.20","1,687.20",,,,,,,,,,,,
Meridian Medicaid,DRG,7522,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$2,102.30 ",IP,"2,102.30","2,102.30",,,,,,,,,,,,
Meridian Medicaid,DRG,7523,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$3,885.72 ",IP,"3,885.72","3,885.72",,,,,,,,,,,,
Meridian Medicaid,DRG,7524,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$13,737.14 ",IP,"13,737.14","13,737.14",,,,,,,,,,,,
Meridian Medicaid,DRG,7531,BIPOLAR DISORDERS,,Relative Weights,"$1,873.11 ",IP,"1,873.11","1,873.11",,,,,,,,,,,,
Meridian Medicaid,DRG,7532,BIPOLAR DISORDERS,,Relative Weights,"$2,183.40 ",IP,"2,183.40","2,183.40",,,,,,,,,,,,
Meridian Medicaid,DRG,7533,BIPOLAR DISORDERS,,Relative Weights,"$3,541.07 ",IP,"3,541.07","3,541.07",,,,,,,,,,,,
Meridian Medicaid,DRG,7534,BIPOLAR DISORDERS,,Relative Weights,"$10,043.84 ",IP,"10,043.84","10,043.84",,,,,,,,,,,,
Meridian Medicaid,DRG,7541,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$1,523.64 ",IP,"1,523.64","1,523.64",,,,,,,,,,,,
Meridian Medicaid,DRG,7542,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$2,007.46 ",IP,"2,007.46","2,007.46",,,,,,,,,,,,
Meridian Medicaid,DRG,7543,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$3,012.23 ",IP,"3,012.23","3,012.23",,,,,,,,,,,,
Meridian Medicaid,DRG,7544,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$7,979.68 ",IP,"7,979.68","7,979.68",,,,,,,,,,,,
Meridian Medicaid,DRG,7551,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$1,532.57 ",IP,"1,532.57","1,532.57",,,,,,,,,,,,
Meridian Medicaid,DRG,7552,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$2,506.06 ",IP,"2,506.06","2,506.06",,,,,,,,,,,,
Meridian Medicaid,DRG,7553,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$3,538.32 ",IP,"3,538.32","3,538.32",,,,,,,,,,,,
Meridian Medicaid,DRG,7554,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$6,118.26 ",IP,"6,118.26","6,118.26",,,,,,,,,,,,
Meridian Medicaid,DRG,7561,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$2,496.79 ",IP,"2,496.79","2,496.79",,,,,,,,,,,,
Meridian Medicaid,DRG,7562,ACUTE ANXIETY & DELIRIUM STATES,,Relative Weights,"$3,057.58 ",IP,"3,057.58","3,057.58",,,,,,,,,,,,
Meridian Medicaid,DRG,7563,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$3,397.43 ",IP,"3,397.43","3,397.43",,,,,,,,,,,,
Meridian Medicaid,DRG,7564,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$7,384.52 ",IP,"7,384.52","7,384.52",,,,,,,,,,,,
Meridian Medicaid,DRG,7571,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$2,504.35 ",IP,"2,504.35","2,504.35",,,,,,,,,,,,
Meridian Medicaid,DRG,7572,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$3,161.02 ",IP,"3,161.02","3,161.02",,,,,,,,,,,,
Meridian Medicaid,DRG,7573,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$5,750.24 ",IP,"5,750.24","5,750.24",,,,,,,,,,,,
Meridian Medicaid,DRG,7574,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$15,933.94 ",IP,"15,933.94","15,933.94",,,,,,,,,,,,
Meridian Medicaid,DRG,7581,BEHAVIORAL DISORDERS,,Relative Weights,"$2,326.35 ",IP,"2,326.35","2,326.35",,,,,,,,,,,,
Meridian Medicaid,DRG,7582,BEHAVIORAL DISORDERS,,Relative Weights,"$2,881.65 ",IP,"2,881.65","2,881.65",,,,,,,,,,,,
Meridian Medicaid,DRG,7583,BEHAVIORAL DISORDERS,,Relative Weights,"$4,037.26 ",IP,"4,037.26","4,037.26",,,,,,,,,,,,
Meridian Medicaid,DRG,7584,BEHAVIORAL DISORDERS,,Relative Weights,"$5,464.00 ",IP,"5,464.00","5,464.00",,,,,,,,,,,,
Meridian Medicaid,DRG,7591,EATING DISORDERS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,,,,,,,
Meridian Medicaid,DRG,7592,EATING DISORDERS,,Relative Weights,"$5,955.04 ",IP,"5,955.04","5,955.04",,,,,,,,,,,,
Meridian Medicaid,DRG,7593,EATING DISORDERS,,Relative Weights,"$9,440.78 ",IP,"9,440.78","9,440.78",,,,,,,,,,,,
Meridian Medicaid,DRG,7594,EATING DISORDERS,,Relative Weights,"$12,954.01 ",IP,"12,954.01","12,954.01",,,,,,,,,,,,
Meridian Medicaid,DRG,7601,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$2,553.48 ",IP,"2,553.48","2,553.48",,,,,,,,,,,,
Meridian Medicaid,DRG,7602,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$3,467.19 ",IP,"3,467.19","3,467.19",,,,,,,,,,,,
Meridian Medicaid,DRG,7603,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$6,902.07 ",IP,"6,902.07","6,902.07",,,,,,,,,,,,
Meridian Medicaid,DRG,7604,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$12,546.82 ",IP,"12,546.82","12,546.82",,,,,,,,,,,,
Meridian Medicaid,DRG,7701,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$1,041.53 ",IP,"1,041.53","1,041.53",,,,,,,,,,,,
Meridian Medicaid,DRG,7702,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$1,522.95 ",IP,"1,522.95","1,522.95",,,,,,,,,,,,
Meridian Medicaid,DRG,7703,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$2,633.89 ",IP,"2,633.89","2,633.89",,,,,,,,,,,,
Meridian Medicaid,DRG,7704,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$6,153.65 ",IP,"6,153.65","6,153.65",,,,,,,,,,,,
Meridian Medicaid,DRG,7721,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$2,743.85 ",IP,"2,743.85","2,743.85",,,,,,,,,,,,
Meridian Medicaid,DRG,7722,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$3,502.58 ",IP,"3,502.58","3,502.58",,,,,,,,,,,,
Meridian Medicaid,DRG,7723,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$4,241.72 ",IP,"4,241.72","4,241.72",,,,,,,,,,,,
Meridian Medicaid,DRG,7724,ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,,,,,,,
Meridian Medicaid,DRG,7731,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,275.88 ",IP,"1,275.88","1,275.88",,,,,,,,,,,,
Meridian Medicaid,DRG,7732,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,881.01 ",IP,"1,881.01","1,881.01",,,,,,,,,,,,
Meridian Medicaid,DRG,7733,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$3,476.12 ",IP,"3,476.12","3,476.12",,,,,,,,,,,,
Meridian Medicaid,DRG,7734,OPIOID ABUSE & DEPENDENCE,,Relative Weights,"$9,565.86 ",IP,"9,565.86","9,565.86",,,,,,,,,,,,
Meridian Medicaid,DRG,7741,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,761.43 ",IP,"1,761.43","1,761.43",,,,,,,,,,,,
Meridian Medicaid,DRG,7742,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,956.95 ",IP,"1,956.95","1,956.95",,,,,,,,,,,,
Meridian Medicaid,DRG,7743,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$3,314.62 ",IP,"3,314.62","3,314.62",,,,,,,,,,,,
Meridian Medicaid,DRG,7744,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$9,105.40 ",IP,"9,105.40","9,105.40",,,,,,,,,,,,
Meridian Medicaid,DRG,7751,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$1,741.50 ",IP,"1,741.50","1,741.50",,,,,,,,,,,,
Meridian Medicaid,DRG,7752,ALCOHOL ABUSE & DEPENDENCE,,Relative Weights,"$2,441.81 ",IP,"2,441.81","2,441.81",,,,,,,,,,,,
Meridian Medicaid,DRG,7753,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$3,986.06 ",IP,"3,986.06","3,986.06",,,,,,,,,,,,
Meridian Medicaid,DRG,7754,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$10,751.37 ",IP,"10,751.37","10,751.37",,,,,,,,,,,,
Meridian Medicaid,DRG,7761,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$2,414.66 ",IP,"2,414.66","2,414.66",,,,,,,,,,,,
Meridian Medicaid,DRG,7762,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,,,,,,,
Meridian Medicaid,DRG,7763,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$4,175.40 ",IP,"4,175.40","4,175.40",,,,,,,,,,,,
Meridian Medicaid,DRG,7764,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$7,699.28 ",IP,"7,699.28","7,699.28",,,,,,,,,,,,
Meridian Medicaid,DRG,7921,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,773.51 ",IP,"7,773.51","7,773.51",,,,,,,,,,,,
Meridian Medicaid,DRG,7922,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$8,931.53 ",IP,"8,931.53","8,931.53",,,,,,,,,,,,
Meridian Medicaid,DRG,7923,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$13,005.21 ",IP,"13,005.21","13,005.21",,,,,,,,,,,,
Meridian Medicaid,DRG,7924,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$27,591.45 ",IP,"27,591.45","27,591.45",,,,,,,,,,,,
Meridian Medicaid,DRG,7931,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$4,608.37 ",IP,"4,608.37","4,608.37",,,,,,,,,,,,
Meridian Medicaid,DRG,7932,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$6,350.90 ",IP,"6,350.90","6,350.90",,,,,,,,,,,,
Meridian Medicaid,DRG,7933,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$9,808.12 ",IP,"9,808.12","9,808.12",,,,,,,,,,,,
Meridian Medicaid,DRG,7934,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$20,177.03 ",IP,"20,177.03","20,177.03",,,,,,,,,,,,
Meridian Medicaid,DRG,7941,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,990.87 ",IP,"3,990.87","3,990.87",,,,,,,,,,,,
Meridian Medicaid,DRG,7942,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,327.92 ",IP,"5,327.92","5,327.92",,,,,,,,,,,,
Meridian Medicaid,DRG,7943,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,911.30 ",IP,"7,911.30","7,911.30",,,,,,,,,,,,
Meridian Medicaid,DRG,7944,NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$16,457.28 ",IP,"16,457.28","16,457.28",,,,,,,,,,,,
Meridian Medicaid,DRG,8101,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$2,594.03 ",IP,"2,594.03","2,594.03",,,,,,,,,,,,
Meridian Medicaid,DRG,8102,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$3,420.11 ",IP,"3,420.11","3,420.11",,,,,,,,,,,,
Meridian Medicaid,DRG,8103,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$5,351.98 ",IP,"5,351.98","5,351.98",,,,,,,,,,,,
Meridian Medicaid,DRG,8104,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$10,772.68 ",IP,"10,772.68","10,772.68",,,,,,,,,,,,
Meridian Medicaid,DRG,8111,ALLERGIC REACTIONS,,Relative Weights,"$1,582.40 ",IP,"1,582.40","1,582.40",,,,,,,,,,,,
Meridian Medicaid,DRG,8112,ALLERGIC REACTIONS,,Relative Weights,"$2,325.66 ",IP,"2,325.66","2,325.66",,,,,,,,,,,,
Meridian Medicaid,DRG,8113,ALLERGIC REACTIONS,,Relative Weights,"$4,003.24 ",IP,"4,003.24","4,003.24",,,,,,,,,,,,
Meridian Medicaid,DRG,8114,ALLERGIC REACTIONS,,Relative Weights,"$9,358.65 ",IP,"9,358.65","9,358.65",,,,,,,,,,,,
Meridian Medicaid,DRG,8121,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$1,778.95 ",IP,"1,778.95","1,778.95",,,,,,,,,,,,
Meridian Medicaid,DRG,8122,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$2,471.70 ",IP,"2,471.70","2,471.70",,,,,,,,,,,,
Meridian Medicaid,DRG,8123,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$3,713.91 ",IP,"3,713.91","3,713.91",,,,,,,,,,,,
Meridian Medicaid,DRG,8124,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$7,487.95 ",IP,"7,487.95","7,487.95",,,,,,,,,,,,
Meridian Medicaid,DRG,8131,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$2,963.09 ",IP,"2,963.09","2,963.09",,,,,,,,,,,,
Meridian Medicaid,DRG,8132,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,546.91 ",IP,"3,546.91","3,546.91",,,,,,,,,,,,
Meridian Medicaid,DRG,8133,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,048.90 ",IP,"5,048.90","5,048.90",,,,,,,,,,,,
Meridian Medicaid,DRG,8134,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$10,108.45 ",IP,"10,108.45","10,108.45",,,,,,,,,,,,
Meridian Medicaid,DRG,8151,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$2,225.32 ",IP,"2,225.32","2,225.32",,,,,,,,,,,,
Meridian Medicaid,DRG,8152,"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",,Relative Weights,"$3,062.74 ",IP,"3,062.74","3,062.74",,,,,,,,,,,,
Meridian Medicaid,DRG,8153,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$5,006.29 ",IP,"5,006.29","5,006.29",,,,,,,,,,,,
Meridian Medicaid,DRG,8154,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$14,243.99 ",IP,"14,243.99","14,243.99",,,,,,,,,,,,
Meridian Medicaid,DRG,8161,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$2,832.85 ",IP,"2,832.85","2,832.85",,,,,,,,,,,,
Meridian Medicaid,DRG,8162,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$3,147.27 ",IP,"3,147.27","3,147.27",,,,,,,,,,,,
Meridian Medicaid,DRG,8163,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$3,543.13 ",IP,"3,543.13","3,543.13",,,,,,,,,,,,
Meridian Medicaid,DRG,8164,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$7,485.21 ",IP,"7,485.21","7,485.21",,,,,,,,,,,,
Meridian Medicaid,DRG,8171,OVERDOSE,,Relative Weights,"$1,970.70 ",IP,"1,970.70","1,970.70",,,,,,,,,,,,
Meridian Medicaid,DRG,8172,OVERDOSE,,Relative Weights,"$2,320.16 ",IP,"2,320.16","2,320.16",,,,,,,,,,,,
Meridian Medicaid,DRG,8173,OVERDOSE,,Relative Weights,"$3,714.94 ",IP,"3,714.94","3,714.94",,,,,,,,,,,,
Meridian Medicaid,DRG,8174,OVERDOSE,,Relative Weights,"$7,902.37 ",IP,"7,902.37","7,902.37",,,,,,,,,,,,
Meridian Medicaid,DRG,8411,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$22,662.13 ",IP,"22,662.13","22,662.13",,,,,,,,,,,,
Meridian Medicaid,DRG,8412,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$23,053.18 ",IP,"23,053.18","23,053.18",,,,,,,,,,,,
Meridian Medicaid,DRG,8413,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$35,475.26 ",IP,"35,475.26","35,475.26",,,,,,,,,,,,
Meridian Medicaid,DRG,8414,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$76,935.80 ",IP,"76,935.80","76,935.80",,,,,,,,,,,,
Meridian Medicaid,DRG,8421,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$7,378.34 ",IP,"7,378.34","7,378.34",,,,,,,,,,,,
Meridian Medicaid,DRG,8422,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$11,298.08 ",IP,"11,298.08","11,298.08",,,,,,,,,,,,
Meridian Medicaid,DRG,8423,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$20,251.94 ",IP,"20,251.94","20,251.94",,,,,,,,,,,,
Meridian Medicaid,DRG,8424,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$47,998.02 ",IP,"47,998.02","47,998.02",,,,,,,,,,,,
Meridian Medicaid,DRG,8431,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,499.14 ",IP,"3,499.14","3,499.14",,,,,,,,,,,,
Meridian Medicaid,DRG,8432,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,888.47 ",IP,"3,888.47","3,888.47",,,,,,,,,,,,
Meridian Medicaid,DRG,8433,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$4,320.07 ",IP,"4,320.07","4,320.07",,,,,,,,,,,,
Meridian Medicaid,DRG,8434,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$12,575.34 ",IP,"12,575.34","12,575.34",,,,,,,,,,,,
Meridian Medicaid,DRG,8441,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$2,201.96 ",IP,"2,201.96","2,201.96",,,,,,,,,,,,
Meridian Medicaid,DRG,8442,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,652.06 ",IP,"3,652.06","3,652.06",,,,,,,,,,,,
Meridian Medicaid,DRG,8443,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$7,050.86 ",IP,"7,050.86","7,050.86",,,,,,,,,,,,
Meridian Medicaid,DRG,8444,PARTIAL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$19,183.95 ",IP,"19,183.95","19,183.95",,,,,,,,,,,,
Meridian Medicaid,DRG,8501,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$9,879.93 ",IP,"9,879.93","9,879.93",,,,,,,,,,,,
Meridian Medicaid,DRG,8502,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$12,498.36 ",IP,"12,498.36","12,498.36",,,,,,,,,,,,
Meridian Medicaid,DRG,8503,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$15,265.59 ",IP,"15,265.59","15,265.59",,,,,,,,,,,,
Meridian Medicaid,DRG,8504,"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",,Relative Weights,"$33,306.29 ",IP,"33,306.29","33,306.29",,,,,,,,,,,,
Meridian Medicaid,DRG,8601,REHABILITATION,REHABILITATION,Relative Weights,"$2,725.99 ",IP,"2,725.99","2,725.99",,,,,,,,,,,,
Meridian Medicaid,DRG,8602,REHABILITATION,REHABILITATION,Relative Weights,"$2,784.40 ",IP,"2,784.40","2,784.40",,,,,,,,,,,,
Meridian Medicaid,DRG,8603,REHABILITATION,REHABILITATION,Relative Weights,"$4,569.88 ",IP,"4,569.88","4,569.88",,,,,,,,,,,,
Meridian Medicaid,DRG,8604,REHABILITATION,REHABILITATION,Relative Weights,"$7,353.25 ",IP,"7,353.25","7,353.25",,,,,,,,,,,,
Meridian Medicaid,DRG,8611,"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",,Relative Weights,"$2,528.74 ",IP,"2,528.74","2,528.74",,,,,,,,,,,,
Meridian Medicaid,DRG,8612,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$3,061.36 ",IP,"3,061.36","3,061.36",,,,,,,,,,,,
Meridian Medicaid,DRG,8613,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$4,043.10 ",IP,"4,043.10","4,043.10",,,,,,,,,,,,
Meridian Medicaid,DRG,8614,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$7,783.47 ",IP,"7,783.47","7,783.47",,,,,,,,,,,,
Meridian Medicaid,DRG,8621,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$2,738.70 ",IP,"2,738.70","2,738.70",,,,,,,,,,,,
Meridian Medicaid,DRG,8622,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$3,392.96 ",IP,"3,392.96","3,392.96",,,,,,,,,,,,
Meridian Medicaid,DRG,8623,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$4,971.92 ",IP,"4,971.92","4,971.92",,,,,,,,,,,,
Meridian Medicaid,DRG,8624,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$9,845.92 ",IP,"9,845.92","9,845.92",,,,,,,,,,,,
Meridian Medicaid,DRG,8631,NEONATAL AFTERCARE,,Relative Weights,"$4,260.96 ",IP,"4,260.96","4,260.96",,,,,,,,,,,,
Meridian Medicaid,DRG,8632,NEONATAL AFTERCARE,,Relative Weights,"$10,340.39 ",IP,"10,340.39","10,340.39",,,,,,,,,,,,
Meridian Medicaid,DRG,8633,NEONATAL AFTERCARE,,Relative Weights,"$23,505.05 ",IP,"23,505.05","23,505.05",,,,,,,,,,,,
Meridian Medicaid,DRG,8634,NEONATAL AFTERCARE,,Relative Weights,"$48,982.51 ",IP,"48,982.51","48,982.51",,,,,,,,,,,,
Meridian Medicaid,DRG,8901,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$3,464.78 ",IP,"3,464.78","3,464.78",,,,,,,,,,,,
Meridian Medicaid,DRG,8902,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$4,475.73 ",IP,"4,475.73","4,475.73",,,,,,,,,,,,
Meridian Medicaid,DRG,8903,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$6,306.22 ",IP,"6,306.22","6,306.22",,,,,,,,,,,,
Meridian Medicaid,DRG,8904,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$13,523.40 ",IP,"13,523.40","13,523.40",,,,,,,,,,,,
Meridian Medicaid,DRG,8921,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$3,450.69 ",IP,"3,450.69","3,450.69",,,,,,,,,,,,
Meridian Medicaid,DRG,8922,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,178.15 ",IP,"4,178.15","4,178.15",,,,,,,,,,,,
Meridian Medicaid,DRG,8923,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,816.26 ",IP,"4,816.26","4,816.26",,,,,,,,,,,,
Meridian Medicaid,DRG,8924,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$8,453.20 ",IP,"8,453.20","8,453.20",,,,,,,,,,,,
Meridian Medicaid,DRG,8931,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$2,817.73 ",IP,"2,817.73","2,817.73",,,,,,,,,,,,
Meridian Medicaid,DRG,8932,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$4,010.80 ",IP,"4,010.80","4,010.80",,,,,,,,,,,,
Meridian Medicaid,DRG,8933,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$5,201.12 ",IP,"5,201.12","5,201.12",,,,,,,,,,,,
Meridian Medicaid,DRG,8934,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$9,134.61 ",IP,"9,134.61","9,134.61",,,,,,,,,,,,
Meridian Medicaid,DRG,8941,HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,,Relative Weights,"$2,969.96 ",IP,"2,969.96","2,969.96",,,,,,,,,,,,
Meridian Medicaid,DRG,8942,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$3,496.05 ",IP,"3,496.05","3,496.05",,,,,,,,,,,,
Meridian Medicaid,DRG,8943,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$4,518.34 ",IP,"4,518.34","4,518.34",,,,,,,,,,,,
Meridian Medicaid,DRG,8944,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$6,751.91 ",IP,"6,751.91","6,751.91",,,,,,,,,,,,
Meridian Medicaid,DRG,9101,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$13,920.63 ",IP,"13,920.63","13,920.63",,,,,,,,,,,,
Meridian Medicaid,DRG,9102,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$15,317.47 ",IP,"15,317.47","15,317.47",,,,,,,,,,,,
Meridian Medicaid,DRG,9103,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$18,619.37 ",IP,"18,619.37","18,619.37",,,,,,,,,,,,
Meridian Medicaid,DRG,9104,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$36,457.00 ",IP,"36,457.00","36,457.00",,,,,,,,,,,,
Meridian Medicaid,DRG,9111,EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$7,838.80 ",IP,"7,838.80","7,838.80",,,,,,,,,,,,
Meridian Medicaid,DRG,9112,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$10,303.63 ",IP,"10,303.63","10,303.63",,,,,,,,,,,,
Meridian Medicaid,DRG,9113,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$13,414.47 ",IP,"13,414.47","13,414.47",,,,,,,,,,,,
Meridian Medicaid,DRG,9114,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$32,085.73 ",IP,"32,085.73","32,085.73",,,,,,,,,,,,
Meridian Medicaid,DRG,9121,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$8,688.93 ",IP,"8,688.93","8,688.93",,,,,,,,,,,,
Meridian Medicaid,DRG,9122,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$9,567.24 ",IP,"9,567.24","9,567.24",,,,,,,,,,,,
Meridian Medicaid,DRG,9123,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$14,948.76 ",IP,"14,948.76","14,948.76",,,,,,,,,,,,
Meridian Medicaid,DRG,9124,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$30,211.60 ",IP,"30,211.60","30,211.60",,,,,,,,,,,,
Meridian Medicaid,DRG,9301,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$3,875.76 ",IP,"3,875.76","3,875.76",,,,,,,,,,,,
Meridian Medicaid,DRG,9302,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$4,609.06 ",IP,"4,609.06","4,609.06",,,,,,,,,,,,
Meridian Medicaid,DRG,9303,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$7,139.17 ",IP,"7,139.17","7,139.17",,,,,,,,,,,,
Meridian Medicaid,DRG,9304,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$15,709.89 ",IP,"15,709.89","15,709.89",,,,,,,,,,,,
Meridian Medicaid,DRG,9501,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,265.63 ",IP,"7,265.63","7,265.63",,,,,,,,,,,,
Meridian Medicaid,DRG,9502,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,410.20 ",IP,"9,410.20","9,410.20",,,,,,,,,,,,
Meridian Medicaid,DRG,9503,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$12,679.80 ",IP,"12,679.80","12,679.80",,,,,,,,,,,,
Meridian Medicaid,DRG,9504,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$27,388.02 ",IP,"27,388.02","27,388.02",,,,,,,,,,,,
Meridian Medicaid,DRG,9511,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,641.31 ",IP,"5,641.31","5,641.31",,,,,,,,,,,,
Meridian Medicaid,DRG,9512,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,394.49 ",IP,"7,394.49","7,394.49",,,,,,,,,,,,
Meridian Medicaid,DRG,9513,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$11,184.68 ",IP,"11,184.68","11,184.68",,,,,,,,,,,,
Meridian Medicaid,DRG,9514,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$22,584.13 ",IP,"22,584.13","22,584.13",,,,,,,,,,,,
Meridian Medicaid,DRG,9521,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,663.69 ",IP,"4,663.69","4,663.69",,,,,,,,,,,,
Meridian Medicaid,DRG,9522,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,212.76 ",IP,"6,212.76","6,212.76",,,,,,,,,,,,
Meridian Medicaid,DRG,9523,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,852.10 ",IP,"9,852.10","9,852.10",,,,,,,,,,,,
Meridian Medicaid,DRG,9524,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$20,519.28 ",IP,"20,519.28","20,519.28",,,,,,,,,,,,
Meridian Medicaid,CPT,100,Anesth salivary gland,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,102,Anesth repair of cleft lip,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,103,Anesth blepharoplasty,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,104,Anesth electroshock,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,120,Anesth ear surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,124,Anesth ear exam,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,126,Anesth tympanotomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,140,Anesth procedures on eye,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,142,Anesth lens surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,144,Anesth corneal transplant,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,145,Anesth vitreoretinal surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,147,Anesth iridectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,148,Anesth eye exam,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,160,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,162,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,164,Anesth biopsy of nose,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,170,Anesth procedure on mouth,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,172,Anesth cleft palate repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,174,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,176,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,190,Anesth face/skull bone surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,192,Anesth facial bone surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,210,Anesth cranial surg nos,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,211,Anesth cran surg hemotoma,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,212,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,214,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,215,Anesth skull repair/fract,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,216,Anesth head vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,218,Anesth special head surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,220,Anesth intrcrn nerve,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,222,Anesth head nerve surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,300,Anesth head/neck/ptrunk,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,320,Anesth neck organ 1yr/>,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,322,Anesth biopsy of thyroid,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,326,Anesth larynx/trach < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,350,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,352,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,400,Anesth skin ext/per/atrunk,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,402,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,404,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,406,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,410,Anesth correct heart rhythm,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,450,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,454,Anesth collar bone biopsy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,470,Anesth removal of rib,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,472,Anesth chest wall repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,474,Anesth surgery of rib,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,500,Anesth esophageal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,520,Anesth chest procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,522,Anesth chest lining biopsy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,524,Anesth chest drainage,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,528,Anes mediascpy & dx thorscpy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,529,Anes medscpy&thorscpy 1 lung,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,530,Anesth pacemaker insertion,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,532,Anesth vascular access,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,534,Anesth cardioverter/defib,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,537,Anesth cardiac electrophys,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,539,Anesth trach-bronch reconst,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,540,Anesth chest surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,541,Anesth one lung ventilation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,542,Anesthesia removal pleura,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,546,Anesth lung chest wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,548,Anesth trachea bronchi surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,550,Anesth sternal debridement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,560,Anesth heart surg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,561,Anesth heart surg <1 yr,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,562,Anesth hrt surg w/pmp age 1+,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,563,Anesth heart surg w/arrest,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,566,Anesth cabg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,567,Anesth cabg w/pump,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,580,Anesth heart/lung transplnt,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,600,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,604,Anesth sitting procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,620,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,625,Anes spine tranthor w/o vent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,626,Anes spine transthor w/vent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,630,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,632,Anesth removal of nerves,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,635,Anesth lumbar puncture,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,640,Anesth spine manipulation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,670,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,700,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,702,Anesth for liver biopsy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,730,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,731,Anes upr gi ndsc px nos,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,732,Anes upr gi ndsc px ercp,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,740,Anesth upper gi visualize,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,750,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,752,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,754,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,756,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,770,Anesth blood vessel repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,790,Anesth surg upper abdomen,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,792,Anesth hemorr/excise liver,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,794,Anesth pancreas removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,796,Anesth for liver transplant,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,797,Anesth surgery for obesity,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,800,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,802,Anesth fat layer removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,810,Anesth low intestine scope,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,811,Anes lwr intst ndsc nos,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,812,Anes lwr intst scr colsc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,813,Anes upr lwr gi ndsc px,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,820,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,830,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,832,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,834,Anesth hernia repair < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,836,Anesth hernia repair preemie,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,840,Anesth surg lower abdomen,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,842,Anesth amniocentesis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,844,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,846,Anesth hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,848,Anesth pelvic organ surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,851,Anesth tubal ligation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,860,Anesth surgery of abdomen,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,862,Anesth kidney/ureter surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,864,Anesth removal of bladder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,865,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,866,Anesth removal of adrenal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,868,Anesth kidney transplant,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,870,Anesth bladder stone surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,872,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,873,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,880,Anesth abdomen vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,882,Anesth major vein ligation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,902,Anesth anorectal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,904,Anesth perineal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,906,Anesth removal of vulva,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,908,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,910,Anesth bladder surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,912,Anesth bladder tumor surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,914,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,916,Anesth bleeding control,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,918,Anesth stone removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,920,Anesth genitalia surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,921,Anesth vasectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,922,Anesth sperm duct surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,924,Anesth testis exploration,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,926,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,928,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,930,Anesth testis suspension,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,932,Anesth amputation of penis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,934,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,936,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,938,Anesth insert penis device,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,940,Anesth vaginal procedures,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,942,Anesth surg on vag/urethral,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,944,Anesth vaginal hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,948,Anesth repair of cervix,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,950,Anesth vaginal endoscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,952,Anesth hysteroscope/graph,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1112,Anesth bone aspirate/bx,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1120,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1130,Anesth body cast procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1140,Anesth amputation at pelvis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1150,Anesth pelvic tumor surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1160,Anesth pelvis procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1170,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1173,Anesth fx repair pelvis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1180,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1190,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1200,Anesth hip joint procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1202,Anesth arthroscopy of hip,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1210,Anesth hip joint surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1212,Anesth hip disarticulation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1214,Anesth hip arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1215,Anesth revise hip repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1220,Anesth procedure on femur,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1230,Anesth surgery of femur,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1232,Anesth amputation of femur,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1234,Anesth radical femur surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1250,Anesth upper leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1260,Anesth upper leg veins surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1270,Anesth thigh arteries surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1272,Anesth femoral artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1274,Anesth femoral embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1320,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1340,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1360,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1380,Anesth knee joint procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1382,Anesth dx knee arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1390,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1392,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1400,Anesth knee joint surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1402,Anesth knee arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1404,Anesth amputation at knee,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1420,Anesth knee joint casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1430,Anesth knee veins surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1432,Anesth knee vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1440,Anesth knee arteries surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1442,Anesth knee artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1444,Anesth knee artery repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1462,Anesth lower leg procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1464,Anesth ankle/ft arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1470,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1472,Anesth achilles tendon surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1474,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1480,Anesth lower leg bone surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1482,Anesth radical leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1484,Anesth lower leg revision,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1486,Anesth ankle replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1490,Anesth lower leg casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1500,Anesth leg arteries surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1502,Anesth lwr leg embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1520,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1522,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1610,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1620,Anesth shoulder procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1622,Anes dx shoulder arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1630,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1634,Anesth shoulder joint amput,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1636,Anesth forequarter amput,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1638,Anesth shoulder replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1650,Anesth shoulder artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1652,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1654,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1656,Anesth arm-leg vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1670,Anesth shoulder vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1680,Anesth shoulder casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1682,Anesth airplane cast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1710,Anesth elbow area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1712,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1714,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1716,Anesth biceps tendon repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1730,Anesth uppr arm procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1732,Anesth dx elbow arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1740,Anesth upper arm surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1742,Anesth humerus surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1744,Anesth humerus repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1756,Anesth radical humerus surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1758,Anesth humeral lesion surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1760,Anesth elbow replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1770,Anesth uppr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1772,Anesth uppr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1780,Anesth upper arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1782,Anesth uppr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1810,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1820,Anesth lower arm procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1829,Anesth dx wrist arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1830,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1832,Anesth wrist replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1840,Anesth lwr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1842,Anesth lwr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1844,Anesth vascular shunt surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1850,Anesth lower arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1852,Anesth lwr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1860,Anesth lower arm casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1916,Anesth dx arteriography,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1920,Anesth catheterize heart,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1922,Anesth cat or mri scan,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1924,Anes ther interven rad artrl,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1925,Anes ther interven rad card,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1926,Anes tx interv rad hrt/cran,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1930,Anes ther interven rad vein,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1931,Anes ther interven rad tips,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1932,Anes tx interv rad th vein,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1933,Anes tx interv rad cran vein,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1935,Anesth perc img dx sp proc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1936,Anesth perc img tx sp proc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1951,Anesth burn less 4 percent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1952,Anesth burn 4-9 percent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1953,Anesth burn each 9 percent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1958,Anesth antepartum manipul,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1960,Anesth vaginal delivery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1961,Anesth cs delivery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1962,Anesth emer hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1963,Anesth cs hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1965,Anesth inc/missed ab proc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1966,Anesth induced ab procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1967,Anesth/analg vag delivery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1968,Anes/analg cs deliver add-on,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1969,Anesth/analg cs hyst add-on,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1991,Anesth nerve block/inj,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1992,Anesth n block/inj prone,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1996,Hosp manage cont drug admin,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,1999,Unlisted anesth procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10004,Fna bx w/o img gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10005,Fna bx w/us gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10006,Fna bx w/us gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10007,Fna bx w/fluor gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10008,Fna bx w/fluor gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10009,Fna bx w/ct gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10010,Fna bx w/ct gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10011,Fna bx w/mr gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10012,Fna bx w/mr gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10021,Fna bx w/o img gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10022,Fna w/image,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10030,Guide cathet fluid drainage,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10040,Acne surgery,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10060,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10061,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10080,Drainage of pilonidal cyst,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10081,Drainage of pilonidal cyst,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10120,Remove foreign body,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10121,Remove foreign body,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10140,Drainage of hematoma/fluid,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,10160,Puncture drainage of lesion,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11055,Trim skin lesion,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11056,Trim skin lesions 2 to 4,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11057,Trim skin lesions over 4,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11100,Biopsy skin lesion,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11101,Biopsy skin add-on,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11102,Tangntl bx skin single les,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11103,Tangntl bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11104,Punch bx skin single lesion,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11105,Punch bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11106,Incal bx skn single les,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11107,Incal bx skn ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11200,Removal of skin tags 2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11305,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11306,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11307,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11308,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11310,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11311,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11312,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11313,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11406,Exc tr-ext b9+marg >4.0 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11446,Exc face-mm b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11450,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11451,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11462,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11463,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11470,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11471,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11606,Exc tr-ext mal+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11719,Trim nail(s) any number,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11720,Debride nail 1-5,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11721,Debride nail 6 or more,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11730,Removal of nail plate,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11732,Remove nail plate add-on,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11740,Drain blood from under nail,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11750,Removal of nail bed,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11752,Remove nail bed/tip,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11755,Biopsy nail unit,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11760,Repair of nail bed,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11762,Reconstruction of nail bed,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11765,Excision of nail fold toe,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11770,Remove pilonidal cyst simple,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11771,Remove pilonidal cyst exten,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11772,Remove pilonidal cyst compl,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11900,Inject skin lesions 7,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11920,Correct skin color 6.0 cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11921,Correct skn color 6.1-20.0cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11922,Correct skin color ea 20.0cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11950,Tx contour defects 1 cc/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11951,Tx contour defects 1.1-5.0cc,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11952,Tx contour defects 5.1-10cc,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11954,Tx contour defects >10.0 cc,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11960,Insert tissue expander(s),General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,11971,Rmvl tis xpndr wo insj implt,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11976,Remove contraceptive capsule,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11980,Implant hormone pellet(s),General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11981,Insert drug implant device,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11982,Remove drug implant device,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,11983,Remove/insert drug implant,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13102,Cmplx rpr trunk addl 5cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13122,Cmplx rpr s/a/l addl 5 cm/>,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13133,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,13153,Cmplx rpr e/n/e/l addl 5cm/<,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15050,Skin pinch graft,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15775,Hair trnspl 1-15 punch grfts,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15776,Hair trnspl >15 punch grafts,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15780,Dermabrasion total face,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15781,Dermabrasion segmental face,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15782,Dermabrasion other than face,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15783,Dermabrasion suprfl any site,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15786,Abrasion lesion single,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15787,Abrasion lesions add-on,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15788,Chemical peel face epiderm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15789,Chemical peel face dermal,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15792,Chemical peel nonfacial,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15793,Chemical peel nonfacial,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15819,Plastic surgery neck,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15820,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15821,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15822,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15823,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15824,Removal of forehead wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15825,Removal of neck wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15826,Removal of brow wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15828,Removal of face wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15829,Removal of skin wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15830,Exc skin abd,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15832,Excise excessive skin thigh,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15833,Excise excessive skin leg,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15834,Excise excessive skin hip,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15835,Excise excessive skin buttck,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15836,Excise excessive skin arm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15837,Excise excess skin arm/hand,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15838,Excise excess skin fat pad,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15839,Excise excess skin & tissue,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15847,Exc skin abd add-on,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15850,Remove sutures same surgeon,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15851,Remove sutures diff surgeon,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,15876,Suction lipectomy head&neck,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15877,Suction lipectomy trunk,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15878,Suction lipectomy upr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,15879,Suction lipectomy lwr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,17000,Destruct premalg lesion,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17003,Destruct premalg les 2-14,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17004,Destroy premal lesions 15/>,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17106,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17107,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17108,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17110,Destruct b9 lesion 1-14,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17111,Destruct lesion 15 or more,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17250,Chem caut of granltj tissue,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17260,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17261,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17262,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17263,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17264,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17266,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17270,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17271,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17272,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17273,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17274,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17276,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17280,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17281,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17282,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17283,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17284,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17286,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17340,Cryotherapy of skin,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17360,Skin peel therapy,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17380,Hair removal by electrolysis,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,17999,Skin tissue procedure,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19000,Drainage of breast lesion,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19001,Drain breast lesion add-on,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19020,Incision of breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19081,Bx breast 1st lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19082,Bx breast add lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19083,Bx breast 1st lesion us imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19084,Bx breast add lesion us imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19085,Bx breast 1st lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19086,Bx breast add lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19100,Bx breast percut w/o image,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19101,Biopsy of breast open,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19105,Cryosurg ablate fa each,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19110,Nipple exploration,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19112,Excise breast duct fistula,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19120,Removal of breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19125,Excision breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19126,Excision addl breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19294,Prep tum cav iort prtl mast,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19297,Place breast cath for rad,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19298,Place breast rad tube/caths,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19300,Removal of breast tissue,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19301,Partial mastectomy,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19302,P-mastectomy w/ln removal,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19303,Mast simple complete,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19304,Mast subq,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19305,Mast radical,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19306,Mast rad urban type,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19307,Mast mod rad,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19316,Suspension of breast,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19318,Breast reduction,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19324,Enlarge breast,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19325,Breast augmentation w/implt,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19328,Rmvl intact breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19330,Rmvl ruptured breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19340,Insj breast implt sm d mast,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19342,Insj/rplcmt brst implt sep d,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19350,Breast reconstruction,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19355,Correct inverted nipple(s),General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19357,Tiss xpndr plmt brst rcnstj,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19361,Brst rcnstj latsms drsi flap,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19364,Brst rcnstj free flap,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19366,Breast reconstruction,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19367,Brst rcnstj 1 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19368,Brst rcnstj 1pdcl tram anast,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19369,Brst rcnstj 2 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19370,Revj peri-implt capsule brst,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19371,Peri-implt capslc brst compl,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19380,Revj reconstructed breast,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,19396,Design custom breast implant,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,19499,Breast surgery procedure,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20206,Needle biopsy muscle,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20220,Bone biopsy trocar/needle,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20500,Injection of sinus tract,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20526,Ther injection carp tunnel,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20527,Inj dupuytren cord w/enzyme,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20550,Inj tendon sheath/ligament,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20551,Inj tendon origin/insertion,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20552,Inj trigger point 1/2 muscl,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20553,Inject trigger points 3/>,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20560,Ndl insj w/o njx 1 or 2 musc,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20561,Ndl insj w/o njx 3+ musc,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20600,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20605,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20610,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20612,Aspirate/inj ganglion cyst,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,20822,Replantation digit complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,20824,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,20827,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,20957,Mt bone graft microvasc,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,20972,Bone/skin graft metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,20973,Bone/skin graft great toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,20999,Musculoskeletal surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21010,Incision of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21025,Excision of bone lower jaw,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21030,Excise max/zygoma b9 tumor,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21031,Remove exostosis mandible,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21032,Remove exostosis maxilla,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21034,Excise max/zygoma mal tumor,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21040,Excise mandible lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21044,Removal of jaw bone lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21045,Extensive jaw surgery,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21046,Remove mandible cyst complex,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21047,Excise lwr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21048,Remove maxilla cyst complex,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21049,Excis uppr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21050,Removal of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21060,Remove jaw joint cartilage,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21070,Remove coronoid process,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21073,Mnpj of tmj w/anesth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21076,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21077,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21079,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21080,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21081,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21082,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21083,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21084,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21085,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21086,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21087,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21088,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21089,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21100,Maxillofacial fixation,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21110,Interdental fixation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21120,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21121,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21122,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21123,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21125,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21127,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21138,Reduction of forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21172,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21175,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21193,Reconst lwr jaw w/o graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21195,Reconst lwr jaw w/o fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21196,Reconst lwr jaw w/fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21198,Reconstr lwr jaw segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21199,Reconstr lwr jaw w/advance,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21206,Reconstruct upper jaw bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21215,Lower jaw bone graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21235,Ear cartilage graft,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21240,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21242,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21243,Reconstruction of jaw joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21244,Reconstruction of lower jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21245,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21246,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21248,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21249,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21270,Augmentation cheek bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21280,Revision of eyelid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21282,Revision of eyelid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21295,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21296,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21315,Closed tx nose fx w/o stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21320,Closed tx nose fx w/ stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21336,Open tx septal fx w/wo stabj,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21337,Closed tx septal&nose fx,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21345,Closed tx nose/jaw fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21346,Opn tx nasomax fx w/fixj,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21400,Closed tx orbit w/o manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21401,Closed tx orbit w/manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21421,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21422,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21440,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21445,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21450,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21451,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21452,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21453,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21454,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21461,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21462,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21465,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21470,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21485,Reset dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21490,Repair dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21495,Treat hyoid bone fracture,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21497,Interdental wiring,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21685,Hyoid myotomy & suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21805,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21811,Optx of rib fx w/fixj scope,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21812,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21813,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,21820,Treat sternum fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,21825,Treat sternum fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,22305,Closed tx spine process fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,22310,Closed tx vert fx w/o manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,22315,Closed tx vert fx w/manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,22505,Manipulation of spine,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,22515,Perq vertebral augmentation,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,22999,Abdomen surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23470,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23472,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23473,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23474,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23500,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23505,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23515,Treat clavicle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23520,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23525,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23530,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23532,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23540,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23545,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23550,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23552,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23570,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23575,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23585,Treat scapula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23600,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23605,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23615,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23616,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23620,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23625,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23630,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23650,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23655,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23660,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23665,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23670,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23675,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23680,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,23700,Fixation of shoulder,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,23929,Shoulder surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24300,Manipulate elbow w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24360,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24361,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24362,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24363,Replace elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24365,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24366,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24370,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24371,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24500,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24505,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24515,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24516,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24530,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24535,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24538,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24545,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24546,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24560,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24565,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24566,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24575,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24576,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24577,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24579,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24582,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24586,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24587,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24600,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24605,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24615,Treat elbow dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24620,Treat elbow fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24635,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24640,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24650,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24655,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24665,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24666,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24670,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24675,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,24685,Treat ulnar fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,24999,Upper arm/elbow surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25001,Incise flexor carpi radialis,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25111,Remove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25112,Reremove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25136,Remove & graft wrist lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25210,Removal of wrist bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25215,Removal of wrist bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25259,Manipulate wrist w/anesthes,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25315,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25316,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25332,Revise wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25394,Repair carpal bone shorten,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25430,Vasc graft into carpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25431,Repair nonunion carpal bone,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25441,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25442,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25443,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25444,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25445,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25446,Wrist replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25447,Repair wrist joints,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25449,Remove wrist joint implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25500,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25505,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25515,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25520,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25525,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25526,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25530,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25535,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25545,Treat fracture of ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25560,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25565,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25574,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25575,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25600,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25605,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25606,Treat fx distal radial,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25607,Treat fx rad extra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25608,Treat fx rad intra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25609,Treat fx radial 3+ frag,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25622,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25624,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25628,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25630,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25635,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25645,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25650,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25651,Pin ulnar styloid fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25652,Treat fracture ulnar styloid,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25660,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25670,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25671,Pin radioulnar dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25675,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25676,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25680,Treat wrist fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25685,Treat wrist fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25690,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25695,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25820,Fusion of hand bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25825,Fuse hand bones with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,25929,Amputation follow-up surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,25999,Forearm or wrist surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26010,Drainage of finger abscess,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26011,Drainage of finger abscess,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26020,Drain hand tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26025,Drainage of palm bursa,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26030,Drainage of palm bursas,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26034,Treat hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26035,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26037,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26040,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26045,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26055,Incise finger tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26060,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26070,Explore/treat hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26075,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26080,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26100,Biopsy hand joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26105,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26110,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26111,Exc hand les sc 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26113,Exc hand tum deep 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26115,Exc hand les sc < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26116,Exc hand tum deep < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26117,Rad resect hand tumor < 3 cm,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26118,Rad resect hand tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26121,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26123,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26125,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26130,Remove wrist joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26135,Revise finger joint each,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26140,Revise finger joint each,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26145,Tendon excision palm/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26160,Remove tendon sheath lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26170,Removal of palm tendon each,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26180,Removal of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26185,Remove finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26200,Remove hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26205,Remove/graft bone lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26210,Removal of finger lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26215,Remove/graft finger lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26230,Partial removal of hand bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26235,Partial removal finger bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26236,Partial removal finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26250,Extensive hand surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26260,Resect prox finger tumor,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26262,Resect distal finger tumor,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26320,Removal of implant from hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26340,Manipulate finger w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26341,Manipulat palm cord post inj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26350,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26352,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26356,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26357,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26358,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26370,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26372,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26373,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26390,Revise hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26392,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26410,Repair hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26412,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26415,Excision hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26416,Graft hand or finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26418,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26420,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26426,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26428,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26432,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26433,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26434,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26437,Realignment of tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26440,Release palm/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26442,Release palm & finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26445,Release hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26449,Release forearm/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26450,Incision of palm tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26455,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26460,Incise hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26471,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26474,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26476,Tendon lengthening,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26477,Tendon shortening,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26478,Lengthening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26479,Shortening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26480,Transplant hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26483,Transplant/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26485,Transplant palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26489,Transplant/graft palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26490,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26492,Tendon transfer with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26494,Hand tendon/muscle transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26496,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26497,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26498,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26499,Revision of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26500,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26502,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26508,Release thumb contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26510,Thumb tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26516,Fusion of knuckle joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26517,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26518,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26520,Release knuckle contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26525,Release finger contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26530,Revise knuckle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26531,Revise knuckle with implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26535,Revise finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26536,Revise/implant finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26540,Repair hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26541,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26542,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26545,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26546,Repair nonunion hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26548,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26550,Construct thumb replacement,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26555,Positional change of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26560,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26561,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26562,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26565,Correct metacarpal flaw,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26567,Correct finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26568,Lengthen metacarpal/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26580,Repair hand deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26587,Reconstruct extra finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26590,Repair finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26591,Repair muscles of hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26593,Release muscles of hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26596,Excision constricting tissue,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26600,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26605,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26607,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26608,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26615,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26641,Treat thumb dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26645,Treat thumb fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26650,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26665,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26670,Treat hand dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26675,Treat hand dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26676,Pin hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26685,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26686,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26700,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26705,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26706,Pin knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26715,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26720,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26725,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26727,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26735,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26740,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26742,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26746,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26750,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26755,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26756,Pin finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26765,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26770,Treat finger dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26775,Treat finger dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26776,Pin finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26785,Treat finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26820,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26841,Fusion of thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26842,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26843,Fusion of hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26844,Fusion/graft of hand joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26850,Fusion of knuckle,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26852,Fusion of knuckle with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26860,Fusion of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26861,Fusion of finger jnt add-on,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26862,Fusion/graft of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26863,Fuse/graft added joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26910,Amputate metacarpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26951,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Meridian Medicaid,CPT,26952,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,26989,Hand/finger surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27125,Partial hip replacement,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27130,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27132,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27134,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27137,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27138,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27175,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27178,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27181,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27193,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27194,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27197,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27198,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27200,Treat tail bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27202,Treat tail bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27215,Treat pelvic fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27216,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27217,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27218,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27220,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27222,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27226,Treat hip wall fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27227,Treat hip fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27230,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27232,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27235,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27236,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27238,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27240,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27246,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27248,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27250,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27252,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27253,Treat hip dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27256,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27257,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27265,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27266,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27267,Cltx thigh fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27268,Cltx thigh fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27269,Optx thigh fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27275,Manipulation of hip joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27299,Pelvis/hip joint surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27412,Autochondrocyte implant knee,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27415,Osteochondral knee allograft,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27437,Revise kneecap,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27438,Revise kneecap with implant,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27440,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27441,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27442,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27443,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27445,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27446,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27447,Total knee arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27486,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27487,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27500,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27501,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27502,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27503,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27507,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27508,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27509,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27510,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27511,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27513,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27514,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27516,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27517,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27520,Treat kneecap fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27524,Treat kneecap fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27530,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27532,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27535,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27536,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27538,Treat knee fracture(s),Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27540,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27550,Treat knee dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27552,Treat knee dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27560,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27562,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27566,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27570,Fixation of knee joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27599,Leg surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27605,Incision of achilles tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27700,Revision of ankle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27702,Reconstruct ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27703,Reconstruction ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27720,Repair of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27722,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27724,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27726,Repair fibula nonunion,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27750,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27752,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27756,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27758,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27759,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27760,Cltx medial ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27762,Cltx med ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27766,Optx medial ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27767,Cltx post ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27768,Cltx post ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27769,Optx post ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27780,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27781,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27784,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27786,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27788,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27792,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27808,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27810,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27814,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27816,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27818,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27822,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27823,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27824,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27825,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27826,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27827,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27828,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27829,Treat lower leg joint,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27830,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27831,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27832,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27840,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27842,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27846,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27848,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,27860,Fixation of ankle joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,27899,Leg/ankle surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28001,Drainage of bursa of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28002,Treatment of foot infection,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28005,Treat foot bone lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28008,Incision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28010,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28011,Incision of toe tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28020,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28022,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28024,Exploration of toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28041,Exc foot/toe tum dep 1.5cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28045,Exc foot/toe tum deep <1.5cm,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28046,Resect foot/toe tumor < 3 cm,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28047,Resect foot/toe tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28050,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28052,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28054,Biopsy of toe joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28055,Neurectomy foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28060,Partial removal foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28062,Removal of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28070,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28072,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28080,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28086,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28088,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28090,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28092,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28100,Removal of ankle/heel lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28102,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28103,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28104,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28106,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28107,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28108,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28110,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28111,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28112,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28113,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28114,Removal of metatarsal heads,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28116,Revision of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28118,Removal of heel bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28119,Removal of heel spur,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28120,Part removal of ankle/heel,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28122,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28124,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28126,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28130,Removal of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28140,Removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28150,Removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28153,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28160,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28171,Resect tarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28173,Resect metatarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28175,Resect phalanx of toe tumor,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28190,Removal of foot foreign body,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28193,Removal of foot foreign body,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28200,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28202,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28208,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28210,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28220,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28222,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28225,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28226,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28230,Incision of foot tendon(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28232,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28234,Incision of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28238,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28240,Release of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28250,Revision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28260,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28261,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28262,Revision of foot and ankle,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28264,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28270,Release of foot contracture,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28272,Release of toe joint each,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28280,Fusion of toes,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28285,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28286,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28288,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28289,Corrj halux rigdus w/o implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28290,Correction of bunion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28291,Corrj halux rigdus w/implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28292,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28293,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28294,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28295,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28296,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28297,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28298,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28299,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28300,Incision of heel bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28302,Incision of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28304,Incision of midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28305,Incise/graft midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28306,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28307,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28308,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28309,Incision of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28310,Revision of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28312,Revision of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28313,Repair deformity of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28315,Removal of sesamoid bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28320,Repair of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28322,Repair of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28340,Resect enlarged toe tissue,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28341,Resect enlarged toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28344,Repair extra toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28345,Repair webbed toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28360,Reconstruct cleft foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28400,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28405,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28406,Treatment of heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28415,Treat heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28420,Treat/graft heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28430,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28435,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28436,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28445,Treat ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28446,Osteochondral talus autogrft,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28450,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28455,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28456,Treat midfoot fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28465,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28470,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28475,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28476,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28485,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28490,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28495,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28496,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28505,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28510,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28515,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28525,Treat toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28530,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28531,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28540,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28545,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28546,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28555,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28570,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28575,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28576,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28585,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28600,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28605,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28606,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28615,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28630,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28635,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28636,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28645,Repair toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28660,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28665,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,28666,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28675,Repair of toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28705,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28715,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28725,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28730,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28735,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28737,Revision of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28740,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28750,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28755,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28760,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28805,Amputation thru metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28810,Amputation toe & metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28820,Amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28825,Partial amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28890,Hi enrgy eswt plantar fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,28899,Foot/toes surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29000,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29010,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29015,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29035,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29040,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29044,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29046,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29049,Application of figure eight,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29055,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29058,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29065,Application of long arm cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29075,Application of forearm cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29085,Apply hand/wrist cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29086,Apply finger cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29105,Apply long arm splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29125,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29126,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29130,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29131,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29200,Strapping of chest,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29240,Strapping of shoulder,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29260,Strapping of elbow or wrist,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29280,Strapping of hand or finger,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29305,Application of hip cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29325,Application of hip casts,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29345,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29355,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29358,Apply long leg cast brace,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29365,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29405,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29425,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29435,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29440,Addition of walker to cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29445,Apply rigid leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29450,Application of leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29505,Application long leg splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29515,Application lower leg splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29520,Strapping of hip,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29530,Strapping of knee,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29540,Strapping of ankle and/or ft,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29550,Strapping of toes,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29580,Application of paste boot,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29581,Apply multlay comprs lwr leg,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29582,Apply multlay comprs upr leg,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29583,Apply multlay comprs upr arm,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29584,Appl multlay comprs arm/hand,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29700,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29705,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29710,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29720,Repair of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29730,Windowing of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29740,Wedging of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29750,Wedging of clubfoot cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29799,Casting/strapping procedure,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,29800,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29804,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29805,Sho arthrs dx +- synovial bx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29806,Sho arthrs srg capsulorpaphy,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29807,Sho arthrs srg rpr slap les,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29819,Sho arthrs srg rmvl loose/fb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29820,Sho arthrs srg prtl synvct,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29821,Sho arthrs srg compl synvct,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29822,Sho arthrs srg lmtd dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29823,Sho arthrs srg xtnsv dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29824,Sho arthrs srg dstl claviclc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29825,Sho arthrs srg lss&rescj ads,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29826,Sho arthrs srg decompression,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29827,Sho arthrs srg rt8tr cuf rpr,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29828,Sho arthrs srg bicp tenodsis,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29830,Elbow arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29834,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29835,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29836,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29837,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29838,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29840,Wrist arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29843,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29844,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29845,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29846,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29847,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29848,Wrist endoscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29850,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29851,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29855,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29856,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29860,Hip arthroscopy dx,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29861,Hip arthro w/fb removal,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29862,Hip arthr0 w/debridement,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29863,Hip arthr0 w/synovectomy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29866,Autgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29867,Allgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29868,Meniscal trnspl knee w/scpe,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29870,Knee arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29871,Knee arthroscopy/drainage,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29873,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29874,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29875,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29876,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29877,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29879,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29880,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29881,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29882,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29883,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29884,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29885,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29886,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29887,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29888,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29889,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29891,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29892,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29893,Scope plantar fasciotomy,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29894,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29895,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29897,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29898,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29899,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29900,Mcp joint arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29901,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29902,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29904,Subtalar arthro w/fb rmvl,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29905,Subtalar arthro w/exc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29906,Subtalar arthro w/deb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29907,Subtalar arthro w/fusion,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29914,Hip arthro w/femoroplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29915,Hip arthro acetabuloplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29916,Hip arthro w/labral repair,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Meridian Medicaid,CPT,29999,Arthroscopy of joint,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30020,Drainage of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30100,Intranasal biopsy,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30110,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30115,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30117,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30118,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30120,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30124,Removal of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30125,Removal of nose lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30130,Excise inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30140,Resect inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30150,Partial removal of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30160,Removal of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30200,Injection treatment of nose,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30220,Insert nasal septal button,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30310,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30320,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30400,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30410,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30420,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30430,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30435,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30450,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30460,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30462,Revision of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30465,Repair nasal stenosis,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30468,Rpr nsl vlv collapse w/implt,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30520,Repair of nasal septum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30540,Repair nasal defect,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30560,Release of nasal adhesions,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30580,Repair upper jaw fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30600,Repair mouth/nose fistula,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30620,Intranasal reconstruction,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30630,Repair nasal septum defect,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30801,Ablate inf turbinate superf,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30802,Ablate inf turbinate submuc,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,30915,Ligation nasal sinus artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30920,Ligation upper jaw artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30930,Ther fx nasal inf turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,30999,Nasal surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31000,Irrigation maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31002,Irrigation sphenoid sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31020,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31030,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31032,Explore sinus remove polyps,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31050,Exploration sphenoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31051,Sphenoid sinus surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31070,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31075,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31080,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31081,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31084,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31085,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31086,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31087,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31090,Exploration of sinuses,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31200,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31201,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31205,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31225,Removal of upper jaw,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31233,Nsl/sins ndsc dx max sinusc,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31235,Nsl/sins ndsc dx sphn sinusc,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31237,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31238,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31239,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31240,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31241,Nsl/sins ndsc w/artery lig,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31253,Nsl/sins ndsc total,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31255,Nsl/sins ndsc w/tot ethmdct,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31256,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31257,Nsl/sins ndsc tot w/sphendt,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31267,Endoscopy maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31287,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31288,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31290,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31291,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31292,Nsl/sins ndsc med/inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31293,Nsl/sins ndsc med&inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31294,Nsl/sins ndsc surg on dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31295,Nsl/sins ndsc surg max sins,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31296,Nsl/sins ndsc surg frnt sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31297,Nsl/sins ndsc surg sphn sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31298,Nsl/sins ndsc surg frnt&sphn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31299,Sinus surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31300,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31320,Diagnostic incision larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31375,Partial removal of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31400,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31420,Removal of epiglottis,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31500,Insert emergency airway,General Medicine,Per Unit,$385.17 ,OP,$385.17 ,$385.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31510,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31512,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31513,Injection into vocal cord,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31515,Laryngoscopy for aspiration,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31520,Dx laryngoscopy newborn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31525,Dx laryngoscopy excl nb,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31526,Dx laryngoscopy w/oper scope,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31527,Laryngoscopy for treatment,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31528,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31529,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31530,Laryngoscopy w/fb removal,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31531,Laryngoscopy w/fb & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31535,Laryngoscopy w/biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31536,Laryngoscopy w/bx & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31540,Laryngoscopy w/exc of tumor,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31541,Larynscop w/tumr exc + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31545,Remove vc lesion w/scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31546,Remove vc lesion scope/graft,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31551,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31552,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31553,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31554,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31560,Laryngoscop w/arytenoidectom,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31561,Larynscop remve cart + scop,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31570,Laryngoscope w/vc inj,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31571,Laryngoscop w/vc inj + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31572,Largsc w/laser dstrj les,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31573,Largsc w/ther injection,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31574,Largsc w/njx augmentation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31576,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31577,Largsc w/rmvl foreign bdy(s),Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31578,Largsc w/removal lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31579,Laryngoscopy telescopic,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31580,Laryngoplasty laryngeal web,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31582,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31584,Laryngoplasty fx rdctj fixj,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31587,Laryngoplasty cricoid split,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31588,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31590,Reinnervate larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31591,Laryngoplasty medialization,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31595,Larynx nerve surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,31599,Larynx surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31615,Visualization of windpipe,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31622,Dx bronchoscope/wash,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31623,Dx bronchoscope/brush,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31624,Dx bronchoscope/lavage,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31625,Bronchoscopy w/biopsy(s),Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31626,Bronchoscopy w/markers,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31627,Navigational bronchoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31628,Bronchoscopy/lung bx each,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31629,Bronchoscopy/needle bx each,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31632,Bronchoscopy/lung bx addl,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31633,Bronchoscopy/needle bx addl,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31635,Bronchoscopy w/fb removal,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31643,Diag bronchoscope/catheter,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31645,Brnchsc w/ther aspir 1st,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31646,Brnchsc w/ther aspir sbsq,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31720,Clearance of airways,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31725,Clearance of airways,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,31899,Airways surgical procedure,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,33206,Insert heart pm atrial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33207,Insert heart pm ventricular,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33208,Insrt heart pm atrial & vent,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33212,Insert pulse gen sngl lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33213,Insert pulse gen dual leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33214,Upgrade of pacemaker system,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33221,Insert pulse gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33224,Insert pacing lead & connect,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33225,L ventric pacing lead add-on,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33226,Reposition l ventric lead,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33227,Remove&replace pm gen singl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33228,Remv&replc pm gen dual lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33229,Remv&replc pm gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33230,Insrt pulse gen w/dual leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33231,Insrt pulse gen w/mult leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33233,Removal of pm generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33240,Insrt pulse gen w/singl lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33241,Remove pulse generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33249,Insj/rplcmt defib w/lead(s),Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33262,Rmvl& replc pulse gen 1 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33270,Ins/rep subq defibrillator,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33274,Tcat insj/rpl perm ldls pm,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33275,Tcat rmvl perm ldls pm w/img,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33282,Implant pat-active ht record,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33285,Insj subq car rhythm mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33289,Tcat impl wrls p-art prs snr,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33889,Artery transpose/endovas taa,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33967,Insert i-aort percut device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33968,Remove aortic assist device,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33990,Insj perq vad l hrt arterial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33991,Insj perq vad l hrt artl&ven,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33992,Rmvl perq left heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33993,Reposg perq r/l hrt vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33995,Insj perq vad r hrt venous,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33997,Rmvl perq right heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,33999,Cardiac surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34001,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34101,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34111,Removal of arm artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34201,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34203,Removal of leg artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34421,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34471,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34490,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34501,Repair valve femoral vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34510,Transposition of vein valve,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34520,Cross-over vein graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34530,Leg vein fusion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34714,Opn fem art expos cndt crtj,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34715,Opn ax/subcla art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34716,Opn ax/subcla art expos cndt,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34812,Opn fem art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,34834,Opn brach art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35011,Repair defect of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35013,Repair artery rupture arm,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35045,Repair defect of arm artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35180,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35184,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35188,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35190,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35201,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35206,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35207,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35226,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35231,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35236,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35256,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35261,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35266,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35301,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35302,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35303,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35304,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35305,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35306,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35321,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35355,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35371,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35372,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35390,Reoperation carotid add-on,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35400,Angioscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,35452,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35472,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35694,Art trnsposj subclav carotid,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35697,Reimplant artery each,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35700,Reoperation bypass graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35701,Expl n/flwd surg neck art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35702,Expl n/flwd surg uxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35703,Expl n/flwd surg lxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35721,Exploration femoral artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35741,Exploration popliteal artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35761,Exploration of artery/vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35800,Explore neck vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35820,Explore chest vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35860,Explore limb vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35875,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35876,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35901,Excision graft neck,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,35903,Excision graft extremity,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36005,Injection ext venography,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36010,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36011,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36012,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36013,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36014,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36015,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36100,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36120,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36140,Intro ndl icath upr/lxtr art,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36160,Establish access to aorta,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36200,Place catheter in aorta,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36215,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36216,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36217,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36218,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36221,Place cath thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36222,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36223,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36224,Place cath carotd art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36225,Place cath subclavian art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36226,Place cath vertebral art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36227,Place cath xtrnl carotid,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36228,Place cath intracranial art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36245,Ins cath abd/l-ext art 1st,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36246,Ins cath abd/l-ext art 2nd,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36247,Ins cath abd/l-ext art 3rd,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36248,Ins cath abd/l-ext art addl,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36251,Ins cath ren art 1st unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36252,Ins cath ren art 1st bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36253,Ins cath ren art 2nd+ unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36254,Ins cath ren art 2nd+ bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36260,Insertion of infusion pump,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36299,Vessel injection procedure,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36430,Blood transfusion service,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36440,Bl push transfuse 2 yr/<,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36450,Bl exchange/transfuse nb,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36455,Bl exchange/transfuse non-nb,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36456,Prtl exchange transfuse nb,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36460,Transfusion service fetal,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36465,Njx noncmpnd sclrsnt 1 vein,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36466,Njx noncmpnd sclrsnt mlt vn,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36468,Njx sclrsnt spider veins,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36470,Njx sclrsnt 1 incmptnt vein,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36471,Njx sclrsnt mlt incmptnt vn,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36481,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36500,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36511,Apheresis wbc,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36512,Apheresis rbc,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36513,Apheresis platelets,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36514,Apheresis plasma,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36515,Apheresis adsorp/reinfuse,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36516,Apheresis immunoads slctv,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36522,Photopheresis,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36557,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36558,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36560,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36561,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36563,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36565,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36566,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36581,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36582,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36583,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36593,Declot vascular device,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36620,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36625,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36640,Insertion catheter artery,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36680,Insert needle bone cavity,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36800,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36810,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36815,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36823,Insertion of cannula(s),Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36838,Dist revas ligation hemo,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36860,External cannula declotting,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,36903,Intro cath dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36905,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36906,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36907,Balo angiop ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36908,Stent plmt ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,36909,Dialysis circuit embolj,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37145,Revision of circulation,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37182,Insert hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37183,Remove hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37184,Prim art m-thrmbc 1st vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37185,Prim art m-thrmbc sbsq vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37186,Sec art thrombectomy add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37195,Thrombolytic therapy stroke,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,37202,Transcatheter therapy infuse,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,37215,Transcath stent cca w/eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37216,Transcath stent cca w/o eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37217,Stent placemt retro carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37218,Stent placemt ante carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37220,Iliac revasc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37221,Iliac revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37222,Iliac revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37223,Iliac revasc w/stent add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37224,Fem/popl revas w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37225,Fem/popl revas w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37226,Fem/popl revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37227,Fem/popl revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37228,Tib/per revasc w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37229,Tib/per revasc w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37230,Tib/per revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37231,Tib/per revasc stent & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37232,Tib/per revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37233,Tibper revasc w/ather add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37234,Revsc opn/prq tib/pero stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37235,Tib/per revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37236,Open/perq place stent 1st,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37237,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37238,Open/perq place stent same,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37239,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37241,Vasc embolize/occlude venous,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37242,Vasc embolize/occlude artery,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37243,Vasc embolize/occlude organ,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37244,Vasc embolize/occlude bleed,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37247,Trluml balo angiop addl art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37249,Trluml balo angiop addl vein,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37250,Iv us first vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,37251,Iv us each add vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,37500,Endoscopy ligate perf veins,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37501,Vascular endoscopy procedure,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,37565,Ligation of neck vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37600,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37605,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37606,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37607,Ligation of a-v fistula,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37609,Temporal artery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37615,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37618,Ligation of extremity artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37619,Ligation of inf vena cava,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37650,Revision of major vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37790,Penile venous occlusion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,37799,Vascular surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38102,Removal of spleen total,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38120,Laparoscopy splenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38129,Laparoscope proc spleen,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38205,Harvest allogeneic stem cell,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38206,Harvest auto stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38207,Cryopreserve stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38208,Thaw preserved stem cells,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,38209,Wash harvest stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38210,T-cell depletion of harvest,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,38211,Tumor cell deplete of harvst,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,38212,Rbc depletion of harvest,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,38213,Platelet deplete of harvest,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,38214,Volume deplete of harvest,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38215,Harvest stem cell concentrte,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38230,Bone marrow harvest allogen,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38232,Bone marrow harvest autolog,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38240,Transplt allo hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38241,Transplt autol hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38242,Transplt allo lymphocytes,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38243,Transplj hematopoietic boost,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38300,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38305,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38308,Incision of lymph channels,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38380,Thoracic duct procedure,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38500,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38505,Needle biopsy lymph nodes,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Meridian Medicaid,CPT,38510,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38520,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38525,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38530,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38531,Open bx/exc inguinofem nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38542,Explore deep node(s) neck,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38550,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38555,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38562,Removal pelvic lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38570,Laparoscopy lymph node biop,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38571,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38572,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38573,Laps pelvic lymphadec,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38589,Laparoscope proc lymphatic,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38700,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38720,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38724,Removal of lymph nodes neck,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38740,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38745,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38747,Remove abdominal lymph nodes,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38760,Remove groin lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,38792,Ra tracer id of sentinl node,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,38794,Access thoracic lymph duct,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,38999,Blood/lymph system procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,39545,Revision of diaphragm,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,39599,Diaphragm surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40490,Biopsy of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40500,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40510,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40520,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40525,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40527,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40530,Partial removal of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40650,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40652,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40654,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40799,Lip surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40801,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40805,Removal foreign body mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40806,Incision of lip fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40808,Biopsy of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40810,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40812,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40814,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40816,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40818,Excise oral mucosa for graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40819,Excise lip or cheek fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40820,Treatment of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40830,Repair mouth laceration,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40831,Repair mouth laceration,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,40840,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40842,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40843,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40844,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40845,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,40899,Mouth surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41000,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41005,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41006,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41007,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41008,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41009,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41010,Incision of tongue fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41015,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41016,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41017,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41018,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41100,Biopsy of tongue,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41105,Biopsy of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41108,Biopsy of floor of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41110,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41112,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41113,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41114,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41115,Excision of tongue fold,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41116,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41120,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41130,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41135,Tongue and neck surgery,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41150,Tongue mouth jaw surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41500,Fixation of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41510,Tongue to lip surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41512,Tongue suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41520,Reconstruction tongue fold,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41530,Tongue base vol reduction,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41599,Tongue and mouth surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41805,Removal foreign body gum,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41806,Removal foreign body jawbone,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41820,Excision gum each quadrant,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41821,Excision of gum flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41822,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41823,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41825,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41826,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41827,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41828,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41830,Removal of gum tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41850,Treatment of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41870,Gum graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,41872,Repair gum,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41874,Repair tooth socket,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,41899,Dental surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42100,Biopsy roof of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42104,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42106,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42107,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42120,Remove palate/lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42140,Excision of uvula,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42160,Treatment mouth roof lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42180,Repair palate,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42182,Repair palate,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42260,Repair nose to lip fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42280,Preparation palate mold,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42281,Insertion palate prosthesis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42299,Palate/uvula surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42300,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42305,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42310,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42320,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42330,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42335,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42340,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42400,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42405,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42408,Excision of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42409,Drainage of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42410,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42415,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42420,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42425,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42426,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42440,Excise submaxillary gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42450,Excise sublingual gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42500,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42505,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42507,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42509,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42510,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42600,Closure of salivary fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42650,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42660,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42665,Ligation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42699,Salivary surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42720,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42725,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42800,Biopsy of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42804,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42806,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42808,Excise pharynx lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42810,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42815,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42820,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42821,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42825,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42826,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42830,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42831,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42835,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42836,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42842,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42844,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42860,Excision of tonsil tags,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42870,Excision of lingual tonsil,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42890,Partial removal of pharynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42892,Revision of pharyngeal walls,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42900,Repair throat wound,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42950,Reconstruction of throat,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42953,Repair throat esophagus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42955,Surgical opening of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42960,Control throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42962,Control throat bleeding,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,42970,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42972,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,42999,Throat surgery procedure,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43020,Incision of esophagus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43030,Throat muscle surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43100,Excision of esophagus lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43130,Removal of esophagus pouch,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43191,Esophagoscopy rigid trnso dx,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43192,Esophagoscp rig trnso inject,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43193,Esophagoscp rig trnso biopsy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43194,Esophagoscp rig trnso rem fb,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43196,Esophagoscp guide wire dilat,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43197,Esophagoscopy flex dx brush,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43198,Esophagosc flex trnsn biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43200,Esophagoscopy flexible brush,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43201,Esoph scope w/submucous inj,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43202,Esophagoscopy flex biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43204,Esoph scope w/sclerosis inj,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43205,Esophagus endoscopy/ligation,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43206,Esoph optical endomicroscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43211,Esophagoscop mucosal resect,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43213,Esophagoscopy retro balloon,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43214,Esophagosc dilate balloon 30,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43215,Esophagoscopy flex remove fb,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43216,Esophagoscopy lesion removal,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43217,Esophagoscopy snare les remv,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43220,Esophagoscopy balloon <30mm,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43226,Esoph endoscopy dilation,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43227,Esophagoscopy control bleed,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43229,Esophagoscopy lesion ablate,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43231,Esophagoscop ultrasound exam,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43232,Esophagoscopy w/us needle bx,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43233,Egd balloon dil esoph30 mm/>,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43235,Egd diagnostic brush wash,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43236,Uppr gi scope w/submuc inj,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43237,Endoscopic us exam esoph,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43238,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43239,Egd biopsy single/multiple,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43241,Egd tube/cath insertion,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43242,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43243,Egd injection varices,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43244,Egd varices ligation,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43245,Egd dilate stricture,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43246,Egd place gastrostomy tube,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43247,Egd remove foreign body,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43248,Egd guide wire insertion,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43249,Esoph egd dilation <30 mm,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43250,Egd cautery tumor polyp,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43251,Egd remove lesion snare,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43253,Egd us transmural injxn/mark,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43254,Egd endo mucosal resection,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43255,Egd control bleeding any,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43257,Egd w/thrml txmnt gerd,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43259,Egd us exam duodenum/jejunum,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43260,Ercp w/specimen collection,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43261,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43262,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43263,Ercp sphincter pressure meas,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43270,Egd lesion ablation,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43275,Ercp remove forgn body duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43276,Ercp stent exchange w/dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43277,Ercp ea duct/ampulla dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43279,Lap myotomy heller,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43280,Laparoscopy fundoplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43281,Lap paraesophag hern repair,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43282,Lap paraesoph her rpr w/mesh,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43283,Lap esoph lengthening,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43284,Laps esophgl sphnctr agmntj,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43285,Rmvl esophgl sphnctr dev,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43289,Laparoscope proc esoph,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43300,Repair of esophagus,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43305,Repair esophagus and fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43320,Fuse esophagus & stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43332,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43333,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43334,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43335,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43336,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43337,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43338,Esoph lengthening,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43401,Esophagus surgery for veins,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43410,Repair esophagus wound,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43420,Repair esophagus opening,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43450,Dilate esophagus 1/mult pass,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43453,Dilate esophagus,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43499,Esophagus surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43500,Surgical opening of stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43510,Surgical opening of stomach,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43520,Incision of pyloric muscle,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43610,Excision of stomach lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43644,Lap gastric bypass/roux-en-y,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43645,Lap gastr bypass incl smll i,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43647,Lap impl electrode antrum,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43648,Lap revise/remv eltrd antrum,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43651,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43652,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43653,Laparoscopy gastrostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43659,Laparoscope proc stom,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43752,Nasal/orogastric w/tube plmt,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43753,Tx gastro intub w/asp,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43754,Dx gastr intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43755,Dx gastr intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43756,Dx duod intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43757,Dx duod intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43760,Change gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43761,Reposition gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43762,Rplc gtube no revj trc,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43763,Rplc gtube revj gstrst trc,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43770,Lap place gastr adj device,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43771,Lap revise gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43772,Lap rmvl gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43773,Lap replace gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43774,Lap rmvl gastr adj all parts,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43775,Lap sleeve gastrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43830,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43831,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43832,Place gastrostomy tube,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43842,V-band gastroplasty,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43843,Gastroplasty w/o v-band,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43848,Revision gastroplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43860,Revise stomach-bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43870,Repair stomach opening,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43880,Repair stomach-bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43881,Impl/redo electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43882,Revise/remove electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,43886,Revise gastric port open,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43887,Remove gastric port open,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43888,Change gastric port open,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,43999,Stomach surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44005,Freeing of bowel adhesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44015,Insert needle cath bowel,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44020,Explore small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44050,Reduce bowel obstruction,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44055,Correct malrotation of bowel,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44100,Biopsy of bowel,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44110,Excise intestine lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44111,Excision of bowel lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44125,Removal of small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44130,Bowel to bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44139,Mobilization of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44141,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44143,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44180,Lap enterolysis,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44186,Lap jejunostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44187,Lap ileo/jejuno-stomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44188,Lap colostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44204,Laparo partial colectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44206,Lap part colectomy w/stoma,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44207,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44208,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44213,Lap mobil splenic fl add-on,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44238,Laparoscope proc intestine,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44300,Open bowel to skin,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44312,Revision of ileostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44320,Colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44340,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44346,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44360,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44361,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44363,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44364,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44365,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44366,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44369,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44370,Small bowel endoscopy/stent,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44372,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44373,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44376,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44377,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44378,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44379,S bowel endoscope w/stent,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44380,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44381,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44382,Small bowel endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44384,Small bowel endoscopy,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44385,Endoscopy of bowel pouch,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44386,Endoscopy bowel pouch/biop,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44388,Colonoscopy thru stoma spx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44389,Colonoscopy with biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44390,Colonoscopy for foreign body,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44391,Colonoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44392,Colonoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44394,Colonoscopy w/snare,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44401,Colonoscopy with ablation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44402,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44403,Colonoscopy w/resection,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44404,Colonoscopy w/injection,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44405,Colonoscopy w/dilation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44406,Colonoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44407,Colonoscopy w/ndl aspir/bx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44408,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44500,Intro gastrointestinal tube,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44602,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44603,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44615,Intestinal stricturoplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44620,Repair bowel opening,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44640,Repair bowel-skin fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44650,Repair bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44799,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44800,Excision of bowel pouch,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44820,Excision of mesentery lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44850,Repair of mesentery,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44899,Bowel surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,44900,Drain appendix abscess open,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44950,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44955,Appendectomy add-on,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44960,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44970,Laparoscopy appendectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,44979,Laparoscope proc app,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45000,Drainage of pelvic abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45005,Drainage of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45020,Drainage of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45100,Biopsy of rectum,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45108,Removal of anorectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45113,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45123,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45130,Excision of rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45136,Excise ileoanal reservior,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45150,Excision of rectal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45160,Excision of rectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45171,Exc rect tum transanal part,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45172,Exc rect tum transanal full,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45190,Destruction rectal tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45300,Proctosigmoidoscopy dx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45303,Proctosigmoidoscopy dilate,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45305,Proctosigmoidoscopy w/bx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45307,Proctosigmoidoscopy fb,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45308,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45309,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45315,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45317,Proctosigmoidoscopy bleed,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45320,Proctosigmoidoscopy ablate,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45321,Proctosigmoidoscopy volvul,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45327,Proctosigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45330,Diagnostic sigmoidoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45331,Sigmoidoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45332,Sigmoidoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45333,Sigmoidoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45334,Sigmoidoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45335,Sigmoidoscopy w/submuc inj,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45337,Sigmoidoscopy & decompress,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45338,Sigmoidoscopy w/tumr remove,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45340,Sig w/tndsc balloon dilation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45341,Sigmoidoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45342,Sigmoidoscopy w/us guide bx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45346,Sigmoidoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45347,Sigmoidoscopy w/plcmt stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45349,Sigmoidoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45350,Sgmdsc w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45378,Diagnostic colonoscopy,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45379,Colonoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45380,Colonoscopy and biopsy,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45381,Colonoscopy submucous njx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45382,Colonoscopy w/control bleed,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45384,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45385,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45386,Colonoscopy w/balloon dilat,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45388,Colonoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45389,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45390,Colonoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45391,Colonoscopy w/endoscope us,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45392,Colonoscopy w/endoscopic fnb,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45393,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45398,Colonoscopy w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45399,Unlisted procedure colon,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45400,Laparoscopic proc,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45402,Lap proctopexy w/sig resect,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45499,Laparoscope proc rectum,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45500,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45505,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45520,Treatment of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45541,Correct rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45560,Repair of rectocele,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45562,Exploration/repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45800,Repair rect/bladder fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45820,Repair rectourethral fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,45900,Reduction of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45905,Dilation of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45910,Dilation of rectal narrowing,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45915,Remove rectal obstruction,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45990,Surg dx exam anorectal,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,45999,Rectum surgery procedure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46020,Placement of seton,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46030,Removal of rectal marker,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46040,Incision of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46045,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46050,Incision of anal abscess,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46060,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46070,Incision of anal septum,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46080,Incision of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46083,Incise external hemorrhoid,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46200,Removal of anal fissure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46220,Excise anal ext tag/papilla,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46221,Ligation of hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46230,Removal of anal tags,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46250,Remove ext hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46255,Remove int/ext hem 1 group,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46257,Remove in/ex hem grp & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46258,Remove in/ex hem grp w/fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46260,Remove in/ex hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46261,Remove in/ex hem grps & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46262,Remove in/ex hem grps w/fist,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46270,Remove anal fist subq,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46275,Remove anal fist inter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46280,Remove anal fist complex,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46285,Remove anal fist 2 stage,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46288,Repair anal fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46320,Removal of hemorrhoid clot,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46500,Injection into hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46505,Chemodenervation anal musc,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46600,Diagnostic anoscopy spx,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46601,Diagnostic anoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46604,Anoscopy and dilation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46606,Anoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46607,Diagnostic anoscopy & biopsy,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46608,Anoscopy remove for body,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46610,Anoscopy remove lesion,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46611,Anoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46612,Anoscopy remove lesions,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46614,Anoscopy control bleeding,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46615,Anoscopy,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46700,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46705,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46706,Repr of anal fistula w/glue,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46707,Repair anorectal fist w/plug,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46710,Repr per/vag pouch sngl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46712,Repr per/vag pouch dbl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46715,Rep perf anoper fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46716,Rep perf anoper/vestib fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46740,Construction of absent anus,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46750,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46751,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46753,Reconstruction of anus,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46754,Removal of suture from anus,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46760,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46761,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46762,Implant artificial sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46900,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46910,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46916,Cryosurgery anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46917,Laser surgery anal lesions,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46922,Excision of anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46924,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46930,Destroy internal hemorrhoids,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46940,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46942,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46945,Int hrhc lig 1 hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46946,Int hrhc lig 2+hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,46947,Hemorrhoidopexy by stapling,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46948,Int hrhc tranal dartlzj 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,46999,Anus surgery procedure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,47370,Laparo ablate liver tumor rf,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47371,Laparo ablate liver cryosurg,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47379,Laparoscope procedure liver,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47510,Insert catheter bile duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47511,Insert bile duct drain,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47525,Change bile duct catheter,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,47530,Revise/reinsert bile tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,47537,Removal biliary drg cath,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,47560,Laparoscopy w/cholangio,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47561,Laparo w/cholangio/biopsy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47562,Laparoscopic cholecystectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47563,Laparo cholecystectomy/graph,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47564,Laparo cholecystectomy/explr,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47570,Laparo cholecystoenterostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47579,Laparoscope proc biliary,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,47630,Remove bile duct stone,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,48550,Donor pancreatectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49000,Exploration of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49002,Reopening of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49010,Exploration behind abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49203,Exc abd tum 5 cm or less,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49204,Exc abd tum over 5 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49205,Exc abd tum over 10 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49215,Excise sacral spine tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49220,Multiple surgery abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49250,Excision of umbilicus,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49255,Removal of omentum,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49320,Diag laparo separate proc,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49321,Laparoscopy biopsy,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49322,Laparoscopy aspiration,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49323,Laparo drain lymphocele,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49324,Lap insert tunnel ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49325,Lap revision perm ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49326,Lap w/omentopexy add-on,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49329,Laparo proc abdm/per/oment,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49402,Remove foreign body adbomen,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49425,Insert abdomen-venous drain,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49426,Revise abdomen-venous shunt,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49428,Ligation of shunt,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49429,Removal of shunt,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49440,Place gastrostomy tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49441,Place duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49442,Place cecostomy tube perc,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49446,Change g-tube to g-j perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49450,Replace g/c tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49451,Replace duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49452,Replace g-j tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49460,Fix g/colon tube w/device,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49491,Rpr hern preemie reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49492,Rpr ing hern premie blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49495,Rpr ing hernia baby reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49496,Rpr ing hernia baby blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49500,Rpr ing hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49501,Rpr ing hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49505,Prp i/hern init reduc >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49507,Prp i/hern init block >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49520,Rerepair ing hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49521,Rerepair ing hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49525,Repair ing hernia sliding,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49540,Repair lumbar hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49550,Rpr rem hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49553,Rpr fem hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49555,Rerepair fem hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49557,Rerepair fem hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49560,Rpr ventral hern init reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49561,Rpr ventral hern init block,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49565,Rerepair ventrl hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49566,Rerepair ventrl hern block,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49568,Hernia repair w/mesh,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49570,Rpr epigastric hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49572,Rpr epigastric hern blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49580,Rpr umbil hern reduc < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49582,Rpr umbil hern block < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49585,Rpr umbil hern reduc > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49587,Rpr umbil hern block > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49590,Repair spigelian hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49600,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49606,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49610,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49650,Lap ing hernia repair init,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49651,Lap ing hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49652,Lap vent/abd hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49653,Lap vent/abd hern proc comp,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49654,Lap inc hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49655,Lap inc hern repair comp,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49656,Lap inc hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49657,Lap inc hern recur comp,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49659,Laparo proc hernia repair,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49900,Repair of abdominal wall,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49904,Omental flap extra-abdom,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,49905,Omental flap intra-abdom,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49906,Free omental flap microvasc,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,49999,Abdomen surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,50389,Remove renal tube w/fluoro,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,50390,Drainage of kidney lesion,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,50391,Instll rx agnt into rnal tub,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,50396,Measure kidney pressure,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,50398,Change kidney tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,50430,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,50431,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,50541,Laparo ablate renal cyst,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,50542,Laparo ablate renal mass,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,50543,Laparo partial nephrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,50544,Laparoscopy pyeloplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,50549,Laparoscope proc renal,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,50945,Laparoscopy ureterolithotomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,50947,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,50948,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,50949,Laparoscope proc ureter,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,51100,Drain bladder by needle,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51500,Removal of bladder cyst,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,51705,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51710,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51715,Endoscopic injection/implant,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51720,Treatment of bladder lesion,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51725,Simple cystometrogram,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51726,Complex cystometrogram,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51727,Cystometrogram w/up,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51728,Cystometrogram w/vp,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51729,Cystometrogram w/vp&up,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51741,Electro-uroflowmetry first,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51784,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51785,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51792,Urinary reflex study,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,51990,Laparo urethral suspension,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,51992,Laparo sling operation,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,51999,Laparoscope proc bla,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,52010,Cystoscopy & duct catheter,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52270,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52275,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52276,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52277,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52282,Cystoscopy implant stent,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52283,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52285,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52400,Cystouretero w/congen repr,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52402,Cystourethro cut ejacul duct,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,52442,Cystourethro w/addl implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,52601,Prostatectomy (turp),Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,52630,Remove prostate regrowth,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,52647,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,52648,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,52649,Prostate laser enucleation,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53000,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53010,Incision of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53020,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53025,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53040,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53060,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53080,Drainage of urinary leakage,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53085,Drainage of urinary leakage,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53200,Biopsy of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53210,Removal of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53215,Removal of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53220,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53230,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53235,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53240,Surgery for urethra pouch,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53250,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53260,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53265,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53270,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53275,Repair of urethra defect,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53400,Revise urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53405,Revise urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53410,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53415,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53420,Reconstruct urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53425,Reconstruct urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53430,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53431,Reconstruct urethra/bladder,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53440,Male sling procedure,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53442,Remove/revise male sling,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53444,Insert tandem cuff,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53446,Remove uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53448,Remov/replc ur sphinctr comp,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53449,Repair uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53450,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53460,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53500,Urethrlys transvag w/ scope,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53502,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53505,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53510,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53515,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53520,Repair of urethra defect,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,53605,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53620,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53621,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53665,Dilation of urethra,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53855,Insert prost urethral stent,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,53860,Transurethral rf treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54000,Slitting of prepuce,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54001,Slitting of prepuce,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54015,Drain penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54050,Destruction penis lesion(s),Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54055,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54056,Cryosurgery penis lesion(s),Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54057,Laser surg penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54060,Excision of penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54065,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54100,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54105,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54110,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54115,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54150,Circumcision w/regionl block,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54160,Circumcision neonate,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54161,Circum 28 days or older,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54162,Lysis penil circumic lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54163,Repair of circumcision,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54164,Frenulotomy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54230,Prepare penis study,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54231,Dynamic cavernosometry,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54300,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54304,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54340,Secondary urethral surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54360,Penis plastic surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54380,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54385,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54400,Insert semi-rigid prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54401,Insert self-contd prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54405,Insert multi-comp penis pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54406,Remove muti-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54408,Repair multi-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54410,Remove/replace penis prosth,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54411,Remov/replc penis pros comp,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54415,Remove self-contd penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54416,Remv/repl penis contain pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54417,Remv/replc penis pros compl,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54420,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54430,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54435,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54440,Repair of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54450,Preputial stretching,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54500,Biopsy of testis,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54505,Biopsy of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54512,Excise lesion testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54520,Removal of testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54522,Orchiectomy partial,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54530,Removal of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54535,Extensive testis surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54550,Exploration for testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54560,Exploration for testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54600,Reduce testis torsion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54620,Suspension of testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54640,Orchiopexy ingun/scrot appr,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54650,Orchiopexy (fowler-stephens),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54660,Revision of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54670,Repair testis injury,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54680,Relocation of testis(es),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54690,Laparoscopy orchiectomy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54692,Laparoscopy orchiopexy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54699,Laparoscope proc testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54700,Drainage of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54800,Biopsy of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54830,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54840,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54860,Removal of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54861,Removal of epididymis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,54865,Explore epididymis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54900,Fusion of spermatic ducts,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,54901,Fusion of spermatic ducts,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55040,Removal of hydrocele,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55041,Removal of hydroceles,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55060,Repair of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55100,Drainage of scrotum abscess,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55110,Explore scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55120,Removal of scrotum lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55150,Removal of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55175,Revision of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55180,Revision of scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55200,Incision of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55250,Removal of sperm duct(s),Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55400,Repair of sperm duct,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55450,Ligation of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55500,Removal of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55520,Removal of sperm cord lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55530,Revise spermatic cord veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55535,Revise spermatic cord veins,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55540,Revise hernia & sperm veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55550,Laparo ligate spermatic vein,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55559,Laparo proc spermatic cord,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55600,Incise sperm duct pouch,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55605,Incise sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55650,Remove sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55680,Remove sperm pouch lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55801,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55810,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55815,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55821,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55831,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55840,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55842,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55845,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55860,Surgical exposure prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55866,Laparo radical prostatectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55870,Electroejaculation,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,55873,Cryoablate prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55874,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55880,Abltj mal prst8 tiss hifu,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,55899,Genital surgery procedure,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,56405,I & d of vulva/perineum,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,56420,Drainage of gland abscess,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,56820,Exam of vulva w/scope,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57150,Treat vagina infection,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57160,Insert pessary/other device,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57170,Fitting of diaphragm/cap,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57220,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57230,Repair of urethral lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57240,Anterior colporrhaphy,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57250,Repair rectum & vagina,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57260,Cmbn ant pst colprhy,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57267,Insert mesh/pelvic flr addon,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,57268,Repair of bowel bulge,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57270,Repair of bowel pouch,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57287,Revise/remove sling repair,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57288,Repair bladder defect,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57289,Repair bladder & vagina,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,57410,Pelvic examination,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,58300,Insert intrauterine device,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,58301,Remove intrauterine device,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,58321,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,58322,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,58323,Sperm washing,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,58970,Retrieval of oocyte,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,58974,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,58976,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59020,Fetal contract stress test,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59025,Fetal non-stress test,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59030,Fetal scalp blood sample,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59050,Fetal monitor w/report,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59072,Umbilical cord occlud w/us,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59074,Fetal fluid drainage w/us,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59076,Fetal shunt placement w/us,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59400,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,59409,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,59410,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,59610,Vbac delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,59612,Vbac delivery only,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,59614,Vbac care after delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,59812,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59820,Care of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59821,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59830,Treat uterus infection,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59840,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59841,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59850,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59851,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59852,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59855,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59856,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59857,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59866,Abortion (mpr),Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,59897,Fetal invas px w/us,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,60000,Drain thyroid/tongue cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,60100,Biopsy of thyroid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,60300,Aspir/inj thyroid cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,60650,Laparoscopy adrenalectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,60659,Laparo proc endocrine,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Meridian Medicaid,CPT,60699,Endocrine surgery procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61000,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,61001,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,61020,Remove brain cavity fluid,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,61026,Injection into brain canal,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,61070,Brain canal shunt procedure,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,61215,Insert brain-fluid device,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61623,Endovasc tempory vessel occl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61624,Transcath occlusion cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61626,Transcath occlusion non-cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61630,Intracranial angioplasty,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61635,Intracran angioplsty w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61640,Dilate ic vasospasm init,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61641,Dilat ic vspsm ea vsl sm ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61642,Dilat ic vspsm ea diff ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61645,Perq art m-thrombect &/nfs,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61651,Evasc prlng admn rx agnt add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61720,Incise skull/brain surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61770,Incise skull for treatment,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61790,Treat trigeminal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,61791,Treat trigeminal tract,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,61796,Srs cranial lesion simple,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61797,Srs cran les simple addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61798,Srs cranial lesion complex,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61799,Srs cran les complex addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61800,Apply srs headframe add-on,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61850,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61880,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61885,Insrt/redo neurostim 1 array,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61886,Implant neurostim arrays,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,61888,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,62000,Treat skull fracture,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62194,Replace/irrigate catheter,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62225,Replace/irrigate catheter,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,62230,Replace/revise brain shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,62252,Csf shunt reprogram,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62292,Njx chemonucleolysis lmbr,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62302,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62303,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62304,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62305,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62310,Inject spine cerv/thoracic,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62311,Inject spine lumbar/sacral,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62318,Inject spine w/cath crv/thrc,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62319,Inject spine w/cath lmb/scrl,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62350,Implant spinal canal cath,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,62355,Remove spinal canal catheter,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62360,Insert spine infusion device,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,62361,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,62362,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,62365,Remove spine infusion device,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62367,Analyze spine infus pump,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62368,Analyze sp inf pump w/reprog,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62369,Anal sp inf pmp w/reprg&fill,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,62370,Anl sp inf pmp w/mdreprg&fil,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,63600,Remove spinal cord lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,63610,Stimulation of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,63615,Remove lesion of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,63620,Srs spinal lesion,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63621,Srs spinal lesion addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63650,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63661,Remove spine eltrd perq aray,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,63662,Remove spine eltrd plate,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,63663,Revise spine eltrd perq aray,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63664,Revise spine eltrd plate,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63685,Insrt/redo spine n generator,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63688,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63707,Repair spinal fluid leakage,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63741,Install spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63744,Revision of spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,63746,Removal of spinal shunt,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64400,Njx aa&/strd trigeminal nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64402,N block inj facial,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64405,Njx aa&/strd gr ocpl nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64408,Njx aa&/strd vagus nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64410,N block inj phrenic,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64412,N block inj spinal accessor,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64413,N block inj cervical plexus,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64415,Njx aa&/strd brach plexus,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64416,Njx aa&/strd brach plex nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64417,Njx aa&/strd axillary nrv,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64418,Njx aa&/strd sprscap nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64420,Njx aa&/strd ntrcost nrv 1,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64421,Njx aa&/strd ntrcost nrv ea,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64425,Njx aa&/strd ii ih nerves,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64430,Njx aa&/strd pudendal nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64435,Njx aa&/strd paracrv nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64445,Njx aa&/strd sciatic nerve,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64446,Njx aa&/strd sciatic nrv nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64447,Njx aa&/strd femoral nerve,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64448,Njx aa&/strd fem nerve nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64449,Njx aa&/strd lmbr plex nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64450,Njx aa&/strd other pn/branch,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64454,Njx aa&/strd gnclr nrv brnch,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64455,Njx aa&/strd pltr com dg nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64486,Tap block unil by injection,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64487,Tap block uni by infusion,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64488,Tap block bi injection,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64489,Tap block bi by infusion,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64505,N block spenopalatine gangl,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64508,N block carotid sinus s/p,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64510,N block stellate ganglion,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64517,N block inj hypogas plxs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64530,N block inj celiac pelus,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64550,Appl surface neurostimulator,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64553,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64555,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64561,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64565,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64566,Neuroeltrd stim post tibial,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64568,Inc for vagus n elect impl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64569,Revise/repl vagus n eltrd,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64570,Remove vagus n eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64575,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64580,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64581,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64585,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64590,Insrt/redo pn/gastr stimul,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64595,Revise/rmv pn/gastr stimul,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64600,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64605,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64610,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64611,Chemodenerv saliv glands,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64612,Destroy nerve face muscle,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64615,Chemodenerv musc migraine,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64616,Chemodenerv musc neck dyston,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64617,Chemodener muscle larynx emg,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64620,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64624,Dstrj nulyt agt gnclr nrv,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64625,Rf abltj nrv nrvtg si jt,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64630,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64632,N block inj common digit,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64640,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64642,Chemodenerv 1 extremity 1-4,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64643,Chemodenerv 1 extrem 1-4 ea,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64644,Chemodenerv 1 extrem 5/> mus,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64645,Chemodenerv 1 extrem 5/> ea,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64646,Chemodenerv trunk musc 1-5,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64647,Chemodenerv trunk musc 6/>,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64650,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64653,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64680,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64681,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64702,Revise finger/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64704,Revise hand/foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64708,Revise arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64712,Revision of sciatic nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64713,Revision of arm nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64714,Revise low back nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64716,Revision of cranial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64718,Revise ulnar nerve at elbow,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64719,Revise ulnar nerve at wrist,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64721,Carpal tunnel surgery,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64722,Relieve pressure on nerve(s),Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64726,Release foot/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64727,Internal nerve revision,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64732,Incision of brow nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64734,Incision of cheek nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64736,Incision of chin nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64738,Incision of jaw nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64740,Incision of tongue nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64742,Incision of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64744,Incise nerve back of head,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64746,Incise diaphragm nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64763,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64766,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64771,Sever cranial nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64772,Incision of spinal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64774,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64776,Remove digit nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64778,Digit nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64782,Remove limb nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64783,Limb nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64784,Remove nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64786,Remove sciatic nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64787,Implant nerve end,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64788,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64790,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64792,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64795,Biopsy of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64802,Sympathectomy cervical,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64804,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64818,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64820,Sympathectomy digital artery,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64821,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64822,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64823,Sympathectomy supfc palmar,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64831,Repair of digit nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64832,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64834,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64835,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64836,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64837,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64840,Repair of leg nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64856,Repair/transpose nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64857,Repair arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64858,Repair sciatic nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64859,Nerve surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64861,Repair of arm nerves,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64862,Repair of low back nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64864,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64865,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64866,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64868,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64872,Subsequent repair of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64874,Repair & revise nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64876,Repair nerve/shorten bone,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64885,Nerve graft head/neck 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64886,Nerve graft head/neck >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64890,Nerve graft hand/foot 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64891,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64892,Nerve graft arm/leg <4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64893,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64895,Nerve graft hand/foot 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64896,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64897,Nerve graft arm/leg 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64898,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64901,Nerve graft add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,64902,Nerve graft add-on,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64905,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64907,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64910,Nerve repair w/allograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64911,Neurorraphy w/vein autograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64912,Nrv rpr w/nrv algrft 1st,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64913,Nrv rpr w/nrv algrft ea addl,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,64999,Nervous system surgery,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65091,Revise eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65093,Revise eye with implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65101,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65103,Remove eye/insert implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65105,Remove eye/attach implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65110,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65112,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65114,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65125,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65130,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65135,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65140,Attach ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65150,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65155,Reinsert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65175,Removal of ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65205,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65210,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65220,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65222,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65235,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65260,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65265,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65270,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65272,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65275,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65280,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65285,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65286,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65290,Repair of eye socket wound,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65400,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65410,Biopsy of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65420,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65426,Removal of eye lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65430,Corneal smear,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65435,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65436,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65450,Treatment of corneal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65600,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65710,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65730,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65750,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65755,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65756,Corneal trnspl endothelial,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65757,Prep corneal endo allograft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65760,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65765,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65767,Corneal tissue transplant,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65770,Revise cornea with implant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65771,Radial keratotomy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65772,Correction of astigmatism,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65775,Correction of astigmatism,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65778,Cover eye w/membrane,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65779,Cover eye w/membrane suture,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65780,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65781,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65782,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65785,Impltj ntrstrml crnl rng seg,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65800,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65810,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65815,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65820,Relieve inner eye pressure,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65850,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65855,Trabeculoplasty laser surg,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65860,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,65865,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65870,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65875,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65880,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65900,Remove eye lesion,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65920,Remove implant of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,65930,Remove blood clot from eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66020,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66030,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66130,Remove eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66150,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66155,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66160,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66170,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66172,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66174,Translum dil eye canal,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66175,Trnslum dil eye canal w/stnt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66179,Aqueous shunt eye w/o graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66180,Aqueous shunt eye w/graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66183,Insert ant drainage device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66184,Revision of aqueous shunt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66185,Revise aqueous shunt eye,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66220,Repair eye lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66225,Repair/graft eye lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66250,Follow-up surgery of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66500,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66505,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66600,Remove iris and lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66605,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66625,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66630,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66635,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66680,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66682,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66700,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66710,Ciliary transsleral therapy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66711,Ecp ciliary body destruction,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66720,Destruction ciliary body,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66740,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66761,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66762,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66770,Removal of inner eye lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66820,Incision secondary cataract,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66821,After cataract laser surgery,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66825,Reposition intraocular lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66830,Removal of lens lesion,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66840,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66850,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66852,Removal of lens material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,66920,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66930,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66940,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66983,Cataract surg w/iol 1 stage,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66984,Xcapsl ctrc rmvl w/o ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66985,Insert lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66986,Exchange lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66988,Xcapsl ctrc rmvl w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,66999,Eye surgery procedure,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67005,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67010,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67015,Release of eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67025,Replace eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67027,Implant eye drug system,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67028,Injection eye drug,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67030,Incise inner eye strands,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67031,Laser surgery eye strands,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67036,Removal of inner eye fluid,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67039,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67040,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67041,Vit for macular pucker,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67042,Vit for macular hole,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67043,Vit for membrane dissect,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67101,Repair detached retina crtx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67105,Repair detached retina pc,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67107,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67108,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67110,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67112,Rerepair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67113,Repair retinal detach cplx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67115,Release encircling material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67120,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67121,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67141,Treatment of retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67145,Treatment of retina,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67208,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67210,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67218,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67220,Treatment of choroid lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67221,Ocular photodynamic ther,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67225,Eye photodynamic ther add-on,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67227,Dstrj extensive retinopathy,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67228,Treatment x10sv retinopathy,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67229,Tr retinal les preterm inf,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67250,Reinforce eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67255,Reinforce/graft eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67299,Eye surgery procedure,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67311,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67312,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67314,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67316,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67318,Revise eye muscle(s),Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67320,Revise eye muscle(s) add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67331,Eye surgery follow-up add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67332,Rerevise eye muscles add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67334,Revise eye muscle w/suture,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67335,Eye suture during surgery,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67340,Revise eye muscle add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67343,Release eye tissue,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67345,Destroy nerve of eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67346,Biopsy eye muscle,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67399,Unlisted px extraocular musc,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Meridian Medicaid,CPT,67400,Explore/biopsy eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67405,Explore/drain eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67412,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67413,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67414,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67415,Aspiration orbital contents,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67445,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67500,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67505,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67515,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67550,Insert eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67560,Revise eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67570,Decompress optic nerve,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67599,Orbit surgery procedure,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67700,Drainage of eyelid abscess,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67710,Incision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67715,Incision of eyelid fold,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67800,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67801,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67805,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67808,Remove eyelid lesion(s),Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67810,Biopsy eyelid & lid margin,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67820,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67825,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67830,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67835,Revise eyelashes,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67840,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67850,Treat eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67875,Closure of eyelid by suture,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67880,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67882,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67900,Repair brow defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67901,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67902,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67903,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67904,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67906,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67908,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67909,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67911,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67912,Correction eyelid w/implant,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67914,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67915,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67916,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67917,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67921,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67922,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67923,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67924,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67930,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67935,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67938,Remove eyelid foreign body,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67950,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67961,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67966,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67971,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67973,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67974,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67975,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,67999,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68020,Incise/drain eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68040,Treatment of eyelid lesions,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68100,Biopsy of eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68110,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68115,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68130,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68135,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68200,Treat eyelid by injection,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68320,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68325,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68326,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68328,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68330,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68335,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68340,Separate eyelid adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68360,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68362,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,68371,Harvest eye tissue alograft,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68399,Eyelid lining surgery,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68400,Incise/drain tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68420,Incise/drain tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68440,Incise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68500,Removal of tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68505,Partial removal tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68510,Biopsy of tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68520,Removal of tear sac,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68525,Biopsy of tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68530,Clearance of tear duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68540,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68550,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68700,Repair tear ducts,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68705,Revise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68720,Create tear sac drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68745,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68750,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68760,Close tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68761,Close tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68770,Close tear system fistula,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68801,Dilate tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68810,Probe nasolacrimal duct,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68811,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68815,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68816,Probe nl duct w/balloon,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68840,Explore/irrigate tear ducts,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,68899,Tear duct system surgery,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69005,Drain external ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69100,Biopsy of external ear,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69105,Biopsy of external ear canal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69110,Remove external ear partial,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69120,Removal of external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69140,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69145,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69150,Extensive ear canal surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69155,Extensive ear/neck surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69205,Clear outer ear canal,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69222,Clean out mastoid cavity,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69300,Revise external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69310,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69320,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69399,Outer ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69421,Incision of eardrum,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69424,Remove ventilating tube,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69433,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69436,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69440,Exploration of middle ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69450,Eardrum revision,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69501,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69502,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69505,Remove mastoid structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69511,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69530,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69540,Remove ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69550,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69552,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69601,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69602,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69603,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69604,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69605,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69610,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69620,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69631,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69632,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69633,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69635,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69636,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69637,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69641,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69642,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69643,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69644,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69645,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69646,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69650,Release middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69660,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69661,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69662,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69666,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69667,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69670,Remove mastoid air cells,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69676,Remove middle ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69700,Close mastoid fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69705,Nps surg dilat eust tube uni,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69706,Nps surg dilat eust tube bi,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69710,Implant/replace hearing aid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69711,Remove/repair hearing aid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69714,Implant temple bone w/stimul,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69715,Temple bne implnt w/stimulat,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69717,Temple bone implant revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69718,Revise temple bone implant,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69720,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69725,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69740,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69745,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69799,Middle ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69801,Incise inner ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69805,Explore inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69806,Explore inner ear,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69820,Establish inner ear window,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69840,Revise inner ear window,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69905,Remove inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69910,Remove inner ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69915,Incise inner ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69930,Implant cochlear device,Otolaryngology Surgery,Per Unit,"$15,529.51 ",OP,"$15,529.51 ","$15,529.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69949,Inner ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,69955,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,69960,Release inner ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Meridian Medicaid,CPT,70010,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70015,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70030,X-ray eye for foreign body,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70100,X-ray exam of jaw <4views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70110,X-ray exam of jaw 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70120,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70130,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70134,X-ray exam of middle ear,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70140,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70150,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70160,X-ray exam of nasal bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70190,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70200,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70210,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70220,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70240,X-ray exam pituitary saddle,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70250,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70260,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70300,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70310,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70320,Full mouth x-ray of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70328,X-ray exam of jaw joint,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70330,X-ray exam of jaw joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70336,Magnetic image jaw joint,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70350,X-ray head for orthodontia,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70355,Panoramic x-ray of jaws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70360,X-ray exam of neck,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70370,Throat x-ray & fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70373,Contrast x-ray of larynx,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70380,X-ray exam of salivary gland,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70450,Ct head/brain w/o dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70460,Ct head/brain w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70470,Ct head/brain w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70480,Ct orbit/ear/fossa w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70481,Ct orbit/ear/fossa w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70486,Ct maxillofacial w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70487,Ct maxillofacial w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70488,Ct maxillofacial w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70490,Ct soft tissue neck w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70491,Ct soft tissue neck w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70492,Ct sft tsue nck w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70496,Ct angiography head,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70498,Ct angiography neck,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70540,Mri orbit/face/neck w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70542,Mri orbit/face/neck w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70543,Mri orbt/fac/nck w/o &w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70544,Mr angiography head w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70545,Mr angiography head w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70546,Mr angiograph head w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70547,Mr angiography neck w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70548,Mr angiography neck w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70549,Mr angiograph neck w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70551,Mri brain stem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70552,Mri brain stem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70553,Mri brain stem w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70554,Fmri brain by tech,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70555,Fmri brain by phys/psych,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70557,Mri brain w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70558,Mri brain w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,70559,Mri brain w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71010,Chest x-ray 1 view frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71015,Chest x-ray stereo frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71020,Chest x-ray 2vw frontal&latl,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71021,Chest x-ray frnt lat lordotc,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71022,Chest x-ray frnt lat oblique,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71023,Chest x-ray and fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71030,Chest x-ray 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71034,Chest x-ray&fluoro 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71035,Chest x-ray special views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71045,X-ray exam chest 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71046,X-ray exam chest 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71047,X-ray exam chest 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71048,X-ray exam chest 4+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71100,X-ray exam ribs uni 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71101,X-ray exam unilat ribs/chest,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71110,X-ray exam ribs bil 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71111,X-ray exam ribs/chest4/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71120,X-ray exam breastbone 2/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71130,X-ray strenoclavic jt 3/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71250,Ct thorax dx c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71260,Ct thorax dx c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71270,Ct thorax dx c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71271,Ct thorax lung cancer scr c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71275,Ct angiography chest,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71550,Mri chest w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71551,Mri chest w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71552,Mri chest w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,71555,Mri angio chest w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72010,X-ray exam spine ap&lat,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72020,X-ray exam of spine 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72040,X-ray exam neck spine 2-3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72050,X-ray exam neck spine 4/5vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72052,X-ray exam neck spine 6/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72069,X-ray exam trunk spine stand,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72070,X-ray exam thorac spine 2vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72072,X-ray exam thorac spine 3vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72074,X-ray exam thorac spine4/>vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72080,X-ray exam thoracolmb 2/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72081,X-ray exam entire spi 1 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72082,X-ray exam entire spi 2/3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72083,X-ray exam entire spi 4/5 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72084,X-ray exam entire spi 6/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72090,X-ray exam scloiosis erect,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72100,X-ray exam l-s spine 2/3 vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72110,X-ray exam l-2 spine 4/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72114,X-ray exam l-s spine bending,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72120,X-ray bend only l-s spine,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72125,Ct neck spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72126,Ct neck spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72127,Ct neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72128,Ct chest spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72129,Ct chest spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72130,Ct chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72131,Ct lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72132,Ct lumbar spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72133,Ct lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72141,Mri neck spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72142,Mri neck spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72146,Mri chest spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72147,Mri chest spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72148,Mri lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72149,Mri lumbar spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72156,Mri neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72157,Mri chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72158,Mri lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72159,Mr angio spine w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72170,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72190,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72191,Ct angiograph pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72192,Ct pelvis w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72193,Ct pelvis w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72194,Ct pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72195,Mri pelvis w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72196,Mri pelvis w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72197,Mri pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72198,Mr angio pelvis w/o & w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72200,X-ray exam si joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72202,X-ray exam si joints 3/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72220,X-ray exam sacrum tailbone,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72240,Myelography neck spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72255,Myelography thoracic spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72265,Myelography l-s spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72270,Myelogphy 2/> spine regions,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72275,Epidurography,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72285,Discography cerv/thor spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,72295,X-ray of lower spine disk,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73000,X-ray exam of collar bone,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73010,X-ray exam of shoulder blade,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73020,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73030,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73050,X-ray exam of shoulders,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73060,X-ray exam of humerus,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73070,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73080,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73090,X-ray exam of forearm,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73092,X-ray exam of arm infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73100,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73110,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73120,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73130,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73140,X-ray exam of finger(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73200,Ct upper extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73201,Ct upper extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73202,Ct uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73206,Ct angio upr extrm w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73218,Mri upper extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73219,Mri upper extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73220,Mri uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73221,Mri joint upr extrem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73222,Mri joint upr extrem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73223,Mri joint upr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73225,Mr angio upr extr w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73500,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73501,X-ray exam hip uni 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73502,X-ray exam hip uni 2-3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73503,X-ray exam hip uni 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73510,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73520,X-ray exam of hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73521,X-ray exam hips bi 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73522,X-ray exam hips bi 3-4 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73523,X-ray exam hips bi 5/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73530,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73540,X-ray exam of pelvis & hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73550,X-ray exam of thigh,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73551,X-ray exam of femur 1,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73552,X-ray exam of femur 2/>,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73560,X-ray exam of knee 1 or 2,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73562,X-ray exam of knee 3,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73564,X-ray exam knee 4 or more,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73565,X-ray exam of knees,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73590,X-ray exam of lower leg,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73592,X-ray exam of leg infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73600,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73610,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73620,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73630,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73650,X-ray exam of heel,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73660,X-ray exam of toe(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73700,Ct lower extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73701,Ct lower extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73702,Ct lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73706,Ct angio lwr extr w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73718,Mri lower extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73719,Mri lower extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73720,Mri lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73721,Mri jnt of lwr extre w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73722,Mri joint of lwr extr w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73723,Mri joint lwr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,73725,Mr ang lwr ext w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74000,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74010,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74018,X-ray exam abdomen 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74019,X-ray exam abdomen 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74020,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74021,X-ray exam abdomen 3+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74022,X-ray exam complete abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74150,Ct abdomen w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74160,Ct abdomen w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74170,Ct abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74174,Ct angio abd&pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74175,Ct angio abdom w/o & w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74176,Ct abd & pelvis w/o contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74177,Ct abd & pelv w/contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74178,Ct abd & pelv 1/> regns,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74181,Mri abdomen w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74182,Mri abdomen w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74183,Mri abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74185,Mri angio abdom w orw/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74210,X-ray xm phrnx&/crv esoph c+,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74220,X-ray xm esophagus 1cntrst,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74235,Remove esophagus obstruction,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74261,Ct colonography dx,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74262,Ct colonography dx w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74263,Ct colonography screening,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74300,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74301,X-rays at surgery add-on,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74305,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74320,Contrast x-ray of bile ducts,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74327,X-ray bile stone removal,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74328,X-ray bile duct endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74329,X-ray for pancreas endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74330,X-ray bile/panc endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74340,X-ray guide for gi tube,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74355,X-ray guide intestinal tube,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74360,X-ray guide gi dilation,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74363,X-ray bile duct dilation,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74475,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74480,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74485,Dilation urtr/urt rs&i,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74710,X-ray measurement of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74712,Mri fetal sngl/1st gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74713,Mri fetal ea addl gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,74742,X-ray fallopian tube,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75557,Cardiac mri for morph,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75559,Cardiac mri w/stress img,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75561,Cardiac mri for morph w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75563,Card mri w/stress img & dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75565,Card mri veloc flow mapping,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75571,Ct hrt w/o dye w/ca test,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75572,Ct hrt w/3d image,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75573,Ct hrt w/3d image congen,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75574,Ct angio hrt w/3d image,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75605,Contrast exam thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,75635,Ct angio abdominal arteries,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75705,Artery x-rays spine,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,75726,Artery x-rays abdomen,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,75736,Artery x-rays pelvis,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,75774,Artery x-ray each vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,75791,Av dialysis shunt imaging,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75842,Vein x-ray adrenal glands,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,75893,Venous sampling by catheter,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,75894,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75896,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75901,Remove cva device obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75902,Remove cva lumen obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75945,Intravascular us,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75946,Intravascular us add-on,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75952,Endovasc repair abdom aorta,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75953,Abdom aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75954,Iliac aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75956,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75957,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75958,Xray place prox ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75959,Xray place dist ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75962,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75964,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75966,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75968,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75970,Vascular biopsy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75980,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75982,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75984,Xray control catheter change,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,75989,Abscess drainage under x-ray,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76010,X-ray nose to rectum,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76100,X-ray exam of body section,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76101,Complex body section x-ray,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76102,Complex body section x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76120,Cine/video x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76125,Cine/video x-rays add-on,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76145,Med physic dos eval rad exps,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76380,Cat scan follow-up study,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76390,Mr spectroscopy,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76391,Mr elastography,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76496,Fluoroscopic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76497,Ct procedure,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76498,Mri procedure,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76499,Radiographic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76506,Echo exam of head,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76510,Oph us dx b-scan&quan a-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76511,Oph us dx quan a-scan only,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76512,Oph us dx b-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76513,Oph us dx ant sgm us uni/bi,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76514,Echo exam of eye thickness,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76516,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76519,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76529,Echo exam of eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76536,Us exam of head and neck,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76604,Us exam chest,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76641,Ultrasound breast complete,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76642,Ultrasound breast limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76700,Us exam abdom complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76705,Echo exam of abdomen,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76706,Us abdl aorta screen aaa,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76770,Us exam abdo back wall comp,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76775,Us exam abdo back wall lim,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76776,Us exam k transpl w/doppler,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76800,Us exam spinal canal,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76801,Ob us < 14 wks single fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76802,Ob us < 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76805,Ob us >= 14 wks sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76810,Ob us >= 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76811,Ob us detailed sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76812,Ob us detailed addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76813,Ob us nuchal meas 1 gest,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76814,Ob us nuchal meas add-on,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76815,Ob us limited fetus(s),Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76816,Ob us follow-up per fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76817,Transvaginal us obstetric,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76818,Fetal biophys profile w/nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76819,Fetal biophys profil w/o nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76820,Umbilical artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76821,Middle cerebral artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76825,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76826,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76827,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76828,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76830,Transvaginal us non-ob,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76831,Echo exam uterus,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76856,Us exam pelvic complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76857,Us exam pelvic limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76870,Us exam scrotum,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76872,Us transrectal,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76873,Echograp trans r pros study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76881,Us compl joint r-t w/img,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76882,Us lmtd jt/nonvasc xtr strux,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76885,Us exam infant hips dynamic,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76886,Us exam infant hips static,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76930,Echo guide cardiocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76932,Echo guide for heart biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76936,Echo guide for artery repair,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76937,Us guide vascular access,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76940,Us guide tissue ablation,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76941,Echo guide for transfusion,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76942,Echo guide for biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76945,Echo guide villus sampling,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76946,Echo guide for amniocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76948,Echo guide ova aspiration,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76965,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76970,Ultrasound exam follow-up,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76975,Gi endoscopic ultrasound,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76977,Us bone density measure,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76978,Us trgt dyn mbubb 1st les,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76979,Us trgt dyn mbubb ea addl,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76981,Use parenchyma,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76982,Use 1st target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76983,Use ea addl target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76998,Us guide intraop,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,76999,Echo examination procedure,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77001,Fluoroguide for vein device,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77002,Needle localization by xray,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77003,Fluoroguide for spine inject,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77011,Ct scan for localization,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77012,Ct scan for needle biopsy,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77013,Ct guide for tissue ablation,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77014,Ct scan for therapy guide,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77021,Mri guidance ndl plmt rs&i,Interventional Radiology,Per Unit,$108.13 ,OP,$108.13 ,$108.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77022,Mri gdn parnchyma tiss abltj,Interventional Radiology,Per Unit,$108.13 ,OP,$108.13 ,$108.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77046,Mri breast c- unilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77047,Mri breast c- bilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77048,Mri breast c-+ w/cad uni,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77049,Mri breast c-+ w/cad bi,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77055,Mammogram one breast,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77056,Mammogram both breasts,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77057,Mammogram screening,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77058,Mri one breast,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77059,Mri both breasts,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77061,Breast tomosynthesis uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77062,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77063,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77065,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77066,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77067,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77072,X-rays for bone age,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77073,X-rays bone length studies,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77074,X-rays bone survey limited,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77076,X-rays bone survey infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77077,Joint survey single view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77078,Ct bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77080,Dxa bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77081,Dxa bone density/peripheral,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77084,Magnetic image bone marrow,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77085,Dxa bone density study,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77086,Fracture assessment via dxa,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77261,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77262,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77263,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77280,Set radiation therapy field,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77285,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77290,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77293,Respirator motion mgmt simul,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77295,3-d radiotherapy plan,Therapeutic Radiology,Per Unit,$68.45 ,OP,$68.45 ,$68.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77299,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77300,Radiation therapy dose plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77301,Radiotherapy dose plan imrt,Therapeutic Radiology,Per Unit,$68.45 ,OP,$68.45 ,$68.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77306,Telethx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77307,Telethx isodose plan cplx,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77316,Brachytx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77317,Brachytx isodose intermed,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77318,Brachytx isodose complex,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77321,Special teletx port plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77331,Special radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77332,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77333,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77334,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77336,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77338,Design mlc device for imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77370,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77371,Srs multisource,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77372,Srs linear based,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77373,Sbrt delivery,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77385,Ntsty modul rad tx dlvr smpl,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77386,Ntsty modul rad tx dlvr cplx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77387,Guidance for radj tx dlvr,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77399,External radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77401,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77402,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77407,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77412,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77417,Radiology port images(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77422,Neutron beam tx simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77423,Neutron beam tx complex,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77424,Io rad tx delivery by x-ray,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77425,Io rad tx deliver by elctrns,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77427,Radiation tx management x5,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77431,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77432,Stereotactic radiation trmt,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77435,Sbrt management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77469,Io radiation tx management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77470,Special radiation treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77499,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77520,Proton trmt simple w/o comp,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77522,Proton trmt simple w/comp,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77523,Proton trmt intermediate,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77525,Proton treatment complex,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77600,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77605,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77610,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77615,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77620,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77750,Infuse radioactive materials,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77761,Apply intrcav radiat simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77762,Apply intrcav radiat interm,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77763,Apply intrcav radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77767,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77768,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77770,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77771,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77772,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77776,Apply interstit radiat simpl,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77777,Apply interstit radiat inter,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77778,Apply interstit radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77785,Hdr brachytx 1 channel,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77786,Hdr brachytx 2-12 channel,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77787,Hdr brachytx over 12 chan,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Meridian Medicaid,CPT,77789,Apply surf ldr radionuclide,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77790,Radiation handling,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,77799,Radium/radioisotope therapy,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78012,Thyroid uptake measurement,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78013,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78014,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78015,Thyroid met imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78016,Thyroid met imaging/studies,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78018,Thyroid met imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78020,Thyroid met uptake,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78070,Parathyroid planar imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78071,Parathyrd planar w/wo subtrj,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78072,Parathyrd planar w/spect&ct,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78075,Adrenal cortex & medulla img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78099,Endocrine nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78102,Bone marrow imaging ltd,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78103,Bone marrow imaging mult,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78104,Bone marrow imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78110,Plasma volume single,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78111,Plasma volume multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78120,Red cell mass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78121,Red cell mass multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78122,Blood volume,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78130,Red cell survival study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78135,Red cell survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78140,Red cell sequestration,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78185,Spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78190,Platelet survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78191,Platelet survival,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78195,Lymph system imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78199,Blood/lymph nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78201,Liver imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78202,Liver imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78205,Liver imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78206,Liver image (3d) with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78215,Liver and spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78216,Liver & spleen image/flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78226,Hepatobiliary system imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78227,Hepatobil syst image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78230,Salivary gland imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78231,Serial salivary imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78232,Salivary gland function exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78258,Esophageal motility study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78261,Gastric mucosa imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78262,Gastroesophageal reflux exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78264,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78265,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78266,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78267,Breath tst attain/anal c-14,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78270,Vit b-12 absorption exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78271,Vit b-12 absrp exam int fac,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78272,Vit b-12 absorp combined,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78278,Acute gi blood loss imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78282,Gi protein loss exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78290,Meckels divert exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78291,Leveen/shunt patency exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78299,Gi nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78300,Bone imaging limited area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78305,Bone imaging multiple areas,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78306,Bone imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78315,Bone imaging 3 phase,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78320,Bone imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78350,Bone mineral single photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78351,Bone mineral dual photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78399,Musculoskeletal nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78414,Non-imaging heart function,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78428,Cardiac shunt imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78429,Myocrd img pet 1 std w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78430,Myocrd img pet rst/strs w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78431,Myocrd img pet rst&strs ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78432,Myocrd img pet 2rtracer,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78433,Myocrd img pet 2rtracer ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78434,Aqmbf pet rest & rx stress,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78445,Vascular flow imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78451,Ht muscle image spect sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78452,Ht muscle image spect mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78453,Ht muscle image planar sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78454,Ht musc image planar mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78456,Acute venous thrombus image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78457,Venous thrombosis imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78458,Ven thrombosis images bilat,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78459,Myocrd img pet single study,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78466,Heart infarct image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78468,Heart infarct image (ef),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78469,Heart infarct image (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78472,Gated heart planar single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78473,Gated heart multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78481,Heart first pass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78483,Heart first pass multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78491,Myocrd img pet 1std rst/strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78492,Myocrd img pet mlt rst&strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78494,Heart image spect,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78496,Heart first pass add-on,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78499,Cardiovascular nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78579,Lung ventilation imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78580,Lung perfusion imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78582,Lung ventilat&perfus imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78597,Lung perfusion differential,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78598,Lung perf&ventilat diferentl,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78599,Respiratory nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78600,Brain image < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78601,Brain image w/flow < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78605,Brain image 4+ views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78606,Brain image w/flow 4 + views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78607,Brain imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78608,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78609,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78610,Brain flow imaging only,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78630,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78635,Csf ventriculography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78645,Csf shunt evaluation,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78647,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78650,Csf leakage imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78660,Nuclear exam of tear flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78699,Nervous system nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78700,Kidney imaging morphol,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78701,Kidney imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78707,K flow/funct image w/o drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78708,K flow/funct image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78709,K flow/funct image multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78710,Kidney imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78725,Kidney function study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78730,Urinary bladder retention,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78740,Ureteral reflux study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78761,Testicular imaging w/flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78799,Genitourinary nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78800,Rp loclzj tum 1 area 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78801,Rp loclzj tum 2+area 1+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78802,Rp loclzj tum whbdy 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78803,Rp loclzj tum spect 1 area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78804,Rp loclzj tum whbdy 2+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78805,Abscess imaging ltd area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78806,Abscess imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78807,Nuclear localization/abscess,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78811,Pet image ltd area,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78812,Pet image skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78813,Pet image full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78814,Pet image w/ct lmtd,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78815,Pet image w/ct skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78816,Pet image w/ct full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78830,Rp loclzj tum spect w/ct 1,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78831,Rp loclzj tum spect 2 areas,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78832,Rp loclzj tum spect w/ct 2,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78835,Rp quan meas single area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,78999,Nuclear diagnostic exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,79005,Nuclear rx oral admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Meridian Medicaid,CPT,79101,Nuclear rx iv admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Meridian Medicaid,CPT,79200,Nuclear rx intracav admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Meridian Medicaid,CPT,79300,Nuclr rx interstit colloid,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Meridian Medicaid,CPT,79403,Hematopoietic nuclear tx,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Meridian Medicaid,CPT,79440,Nuclear rx intra-articular,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Meridian Medicaid,CPT,79445,Nuclear rx intra-arterial,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Meridian Medicaid,CPT,79999,Nuclear medicine therapy,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80047,Metabolic panel ionized ca,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80048,Metabolic panel total ca,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80050,General health panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80051,Electrolyte panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80053,Comprehen metabolic panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80055,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80061,Lipid panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80069,Renal function panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80074,Acute hepatitis panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80076,Hepatic function panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80081,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80143,Drug assay acetaminophen,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80145,Drug assay adalimumab,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80150,Assay of amikacin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80151,Drug assay amiodarone,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80155,Drug assay caffeine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80156,Assay carbamazepine total,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80157,Assay carbamazepine free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80158,Drug assay cyclosporine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80159,Drug assay clozapine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80161,"Asy carbamazepin 10,11-epxid",Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80162,Assay of digoxin total,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80163,Assay of digoxin free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80164,Assay dipropylacetic acd tot,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80165,Dipropylacetic acid free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80167,Drug assay felbamate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80168,Assay of ethosuximide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80169,Drug assay everolimus,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80170,Assay of gentamicin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80171,Drug screen quant gabapentin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80173,Assay of haloperidol,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80175,Drug screen quan lamotrigine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80176,Assay of lidocaine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80177,Drug scrn quan levetiracetam,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80178,Assay of lithium,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80179,Drug assay salicylate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80180,Drug scrn quan mycophenolate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80181,Drug assay flecainide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80183,Drug scrn quant oxcarbazepin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80184,Assay of phenobarbital,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80185,Assay of phenytoin total,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80186,Assay of phenytoin free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80187,Drug assay posaconazole,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80188,Assay of primidone,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80189,Drug assay itraconzaole,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80190,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80192,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80193,Drug assay leflunomide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80194,Assay of quinidine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80195,Assay of sirolimus,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80197,Assay of tacrolimus,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80198,Assay of theophylline,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80199,Drug screen quant tiagabine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80200,Assay of tobramycin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80201,Assay of topiramate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80202,Assay of vancomycin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80203,Drug screen quant zonisamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80204,Drug assay methotrexate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80210,Drug assay rufinamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80230,Drug assay infliximab,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80235,Drug assay lacosamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80280,Drug assay vedolizumab,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80285,Drug assay voriconazole,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80299,Quantitative assay drug,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80300,Drug screen non tlc devices,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80301,Drug screen class list a,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80302,Drug screen prsmptv 1 class,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80303,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80304,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80305,Drug test prsmv dir opt obs,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80306,Drug test prsmv instrmnt,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80307,Drug test prsmv chem anlyzr,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80320,Drug screen quantalcohols,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80321,Alcohols biomarkers 1or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80322,Alcohols biomarkers 3/more,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80323,Alkaloids nos,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80324,Drug screen amphetamines 1/2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80325,Amphetamines 3or 4,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80326,Amphetamines 5 or more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80327,Anabolic steroid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80328,Anabolic steroid 3 or more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80329,Analgesics non-opioid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80330,Analgesics non-opioid 3-5,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80331,Analgesics non-opioid 6/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80332,Antidepressants class 1 or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80333,Antidepressants class 3-5,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80334,Antidepressants class 6/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80335,Antidepressant tricyclic 1/2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80336,Antidepressant tricyclic 3-5,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80337,Tricyclic & cyclicals 6/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80338,Antidepressant not specified,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80339,Antiepileptics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80340,Antiepileptics nos 4-6,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80341,Antiepileptics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80342,Antipsychotics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80343,Antipsychotics nos 4-6,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80344,Antipsychotics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80345,Drug screening barbiturates,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80346,Benzodiazepines1-12,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80347,Benzodiazepines 13 or more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80348,Drug screening buprenorphine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80349,Cannabinoids natural,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80350,Cannabinoids synthetic 1-3,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80351,Cannabinoids synthetic 4-6,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80352,Cannabinoid synthetic 7/more,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80353,Drug screening cocaine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80354,Drug screening fentanyl,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80355,Gabapentin non-blood,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80356,Heroin metabolite,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80357,Ketamine and norketamine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80358,Drug screening methadone,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80359,Methylenedioxyamphetamines,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80360,Methylphenidate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80361,Opiates 1 or more,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80362,Opioids & opiate analogs 1/2,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80363,Opioids & opiate analogs 3/4,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80364,Opioid &opiate analog 5/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80365,Drug screening oxycodone,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80366,Drug screening pregabalin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80367,Drug screening propoxyphene,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80368,Sedative hypnotics,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80369,Skeletal muscle relaxant 1/2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80370,Skel musc relaxant 3 or more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80371,Stimulants synthetic,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80372,Drug screening tapentadol,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80373,Drug screening tramadol,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80374,Stereoisomer analysis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80375,Drug/substance nos 1-3,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80376,Drug/substance nos 4-6,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80377,Drug/substance nos 7/more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80400,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80402,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80406,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80408,Aldosterone suppression eval,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80410,Calcitonin stimul panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80412,Crh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80414,Testosterone response panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80415,Tot estradiol response panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80416,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80417,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80418,Pituitary evaluation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80420,Dexamethasone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80422,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80424,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80426,Gonadotropin hormone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80428,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80430,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80432,Insulin suppression panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80434,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80435,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80436,Metyrapone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80438,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80439,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80500,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,80502,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81000,Urinalysis nonauto w/scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81001,Urinalysis auto w/scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81002,Urinalysis nonauto w/o scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81003,Urinalysis auto w/o scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81005,Urinalysis,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81007,Urine screen for bacteria,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81015,Microscopic exam of urine,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81020,Urinalysis glass test,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81025,Urine pregnancy test,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81050,Urinalysis volume measure,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81099,Urinalysis test procedure,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81105,Hpa-1 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81106,Hpa-2 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81107,Hpa-3 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81108,Hpa-4 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81109,Hpa-5 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81110,Hpa-6 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81111,Hpa-9 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81112,Hpa-15 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81120,Idh1 common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81121,Idh2 common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81161,Dmd dup/delet analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81162,Brca1&2 gen full seq dup/del,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81163,Brca1&2 gene full seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81164,Brca1&2 gen ful dup/del alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81165,Brca1 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81166,Brca1 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81167,Brca2 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81168,Ccnd1/igh translocation alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81170,Abl1 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81171,Aff2 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81172,Aff2 gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81173,Ar gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81174,Ar gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81175,Asxl1 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81176,Asxl1 gene target seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81177,Atn1 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81178,Atxn1 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81179,Atxn2 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81180,Atxn3 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81181,Atxn7 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81182,Atxn8os gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81183,Atxn10 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81184,Cacna1a gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81185,Cacna1a gene full gene seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81186,Cacna1a gen known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81187,Cnbp gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81188,Cstb gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81189,Cstb gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81190,Cstb gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81191,Ntrk1 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81192,Ntrk2 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81193,Ntrk3 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81194,Ntrk translocation analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81200,Aspa gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81201,Apc gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81202,Apc gene known fam variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81203,Apc gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81204,Ar gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81205,Bckdhb gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81206,Bcr/abl1 gene major bp,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81207,Bcr/abl1 gene minor bp,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81208,Bcr/abl1 gene other bp,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81209,Blm gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81210,Braf gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81211,Brca1&2 seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81212,Brca1&2 185&5385&6174 vrnt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81213,Brca1&2 uncom dup/del var,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81214,Brca1 full seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81215,Brca1 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81216,Brca2 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81217,Brca2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81218,Cebpa gene full sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81219,Calr gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81220,Cftr gene com variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81221,Cftr gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81222,Cftr gene dup/delet variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81223,Cftr gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81224,Cftr gene intron poly t,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81225,Cyp2c19 gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81226,Cyp2d6 gene com variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81227,Cyp2c9 gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81228,Cytogen micrarray copy nmbr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81229,Cytogen m array copy no&snp,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81230,Cyp3a4 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81231,Cyp3a5 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81232,Dpyd gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81233,Btk gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81234,Dmpk gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81235,Egfr gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81236,Ezh2 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81237,Ezh2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81238,F9 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81239,Dmpk gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81240,F2 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81241,F5 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81242,Fancc gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81243,Fmr1 gene detection,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81244,Fmr1 gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81245,Flt3 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81246,Flt3 gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81247,G6pd gene alys cmn variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81248,G6pd known familial variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81249,G6pd full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81250,G6pc gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81251,Gba gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81252,Gjb2 gene full sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81253,Gjb2 gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81254,Gjb6 gene com variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81255,Hexa gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81256,Hfe gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81257,Hba1/hba2 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81258,Hba1/hba2 gene fam vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81259,Hba1/hba2 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81260,Ikbkap gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81261,Igh gene rearrange amp meth,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81262,Igh gene rearrang dir probe,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81263,Igh vari regional mutation,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81264,Igk rearrangeabn clonal pop,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81265,Str markers specimen anal,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81266,Str markers spec anal addl,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81267,Chimerism anal no cell selec,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81268,Chimerism anal w/cell select,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81269,Hba1/hba2 gene dup/del vrnts,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81270,Jak2 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81271,Htt gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81272,Kit gene targeted seq analys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81273,Kit gene analys d816 variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81274,Htt gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81275,Kras gene variants exon 2,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81276,Kras gene addl variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81277,Cytogenomic neo microra alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81278,Igh/bcl2 translocation alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81279,Jak2 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81280,Long qt synd gene full seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81281,Long qt synd known fam var,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81282,Long qt syn gene dup/dlt var,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81283,Ifnl3 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81284,Fxn gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81285,Fxn gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81286,Fxn gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81287,Mgmt gene prmtr mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81288,Mlh1 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81289,Fxn gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81290,Mcoln1 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81291,Mthfr gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81292,Mlh1 gene full seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81293,Mlh1 gene known variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81294,Mlh1 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81295,Msh2 gene full seq,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81296,Msh2 gene known variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81297,Msh2 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81298,Msh6 gene full seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81299,Msh6 gene known variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81300,Msh6 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81301,Microsatellite instability,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81302,Mecp2 gene full seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81303,Mecp2 gene known variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81304,Mecp2 gene dup/delet variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81305,Myd88 gene p.leu265pro vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81306,Nudt15 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81307,Palb2 gene full gene seq,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81308,Palb2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81309,Pik3ca gene trgt seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81310,Npm1 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81311,Nras gene variants exon 2&3,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81312,Pabpn1 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81313,Pca3/klk3 antigen,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81314,Pdgfra gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81315,Pml/raralpha com breakpoints,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81316,Pml/raralpha 1 breakpoint,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81317,Pms2 gene full seq analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81318,Pms2 known familial variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81319,Pms2 gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81320,Plcg2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81321,Pten gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81322,Pten gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81323,Pten gene dup/delet variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81324,Pmp22 gene dup/delet,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81325,Pmp22 gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81326,Pmp22 gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81327,Sept9 gen prmtr mthyltn alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81328,Slco1b1 gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81329,Smn1 gene dos/deletion alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81330,Smpd1 gene common variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81331,Snrpn/ube3a gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81332,Serpina1 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81333,Tgfbi gene common variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81334,Runx1 gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81335,Tpmt gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81336,Smn1 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81337,Smn1 gen nown famil seq vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81338,Mpl gene common variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81339,Mpl gene seq alys exon 10,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81340,Trb@ gene rearrange amplify,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81341,Trb@ gene rearrange dirprobe,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81342,Trg gene rearrangement anal,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81343,Ppp2r2b gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81344,Tbp gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81345,Tert gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81346,Tyms gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81347,Sf3b1 gene common variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81348,Srsf2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81350,Ugt1a1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81351,Tp53 gene full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81352,Tp53 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81353,Tp53 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81355,Vkorc1 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81357,U2af1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81360,Zrsr2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81361,Hbb gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81362,Hbb gene known fam variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81363,Hbb gene dup/del variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81364,Hbb full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81370,Hla i & ii typing lr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81371,Hla i & ii type verify lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81372,Hla i typing complete lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81373,Hla i typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81374,Hla i typing 1 antigen lr,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81375,Hla ii typing ag equiv lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81376,Hla ii typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81377,Hla ii type 1 ag equiv lr,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81378,Hla i & ii typing hr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81379,Hla i typing complete hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81380,Hla i typing 1 locus hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81381,Hla i typing 1 allele hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81382,Hla ii typing 1 loc hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81383,Hla ii typing 1 allele hr,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81400,Mopath procedure level 1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81401,Mopath procedure level 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81402,Mopath procedure level 3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81403,Mopath procedure level 4,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81404,Mopath procedure level 5,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81405,Mopath procedure level 6,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81406,Mopath procedure level 7,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81407,Mopath procedure level 8,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81408,Mopath procedure level 9,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81410,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81411,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81412,Ashkenazi jewish assoc dis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81413,Car ion chnnlpath inc 10 gns,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81414,Car ion chnnlpath inc 2 gns,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81415,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81416,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81417,Exome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81419,Epilepsy gen seq alys panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81420,Fetal chrmoml aneuploidy,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81422,Fetal chrmoml microdeltj,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81425,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81426,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81427,Genome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81430,Hearing loss sequence analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81431,Hearing loss dup/del analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81434,Hereditary retinal disorders,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81435,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81436,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81437,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81438,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81439,Hrdtry cardmypy gene panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81440,Mitochondrial gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81442,Noonan spectrum disorders,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81443,Genetic tstg severe inh cond,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81445,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81448,Hrdtry perph neurphy panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81450,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81455,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81460,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81465,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81470,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81471,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81479,Unlisted molecular pathology,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81490,Autoimmune rheumatoid arthr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81493,Cor artery disease mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81500,Onco (ovar) two proteins,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81503,Onco (ovar) five proteins,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81504,Oncology tissue of origin,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81506,Endo assay seven anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81507,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81508,Ftl cgen abnor two proteins,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81509,Ftl cgen abnor 3 proteins,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81510,Ftl cgen abnor three anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81511,Ftl cgen abnor four anal,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81512,Ftl cgen abnor five anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81513,Nfct ds bv rna vag flu alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81514,Nfct ds bv&vaginitis dna alg,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81518,Onc brst mrna 11 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81519,Oncology breast mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81520,Onc breast mrna 58 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81521,Onc breast mrna 70 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81522,Onc breast mrna 12 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81525,Oncology colon mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81528,Oncology colorectal scr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81529,Onc cutan mlnma mrna 31 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81535,Oncology gynecologic,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81536,Oncology gynecologic,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81538,Oncology lung,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81539,Oncology prostate prob score,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81540,Oncology tum unknown origin,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81541,Onc prostate mrna 46 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81542,Onc prostate mrna 22 cnt gen,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81545,Oncology thyroid,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81546,"Onc thyr mrna 10,196 gen alg",Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81551,Onc prostate 3 genes,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81552,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81554,Pulm ds ipf mrna 190 gen alg,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81595,Cardiology hrt trnspl mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81596,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,81599,Unlisted maaa,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82009,Test for acetone/ketones,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82010,Acetone assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82013,Acetylcholinesterase assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82016,Acylcarnitines qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82017,Acylcarnitines quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82024,Assay of acth,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82030,Assay of adp & amp,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82040,Assay of serum albumin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82042,Other source albumin quan ea,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82043,Ur albumin quantitative,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82044,Ur albumin semiquantitative,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82045,Albumin ischemia modified,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82075,Assay of breath ethanol,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82077,Assay spec xcp ur&breath ia,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82085,Assay of aldolase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82088,Assay of aldosterone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82103,Alpha-1-antitrypsin total,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82104,Alpha-1-antitrypsin pheno,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82105,Alpha-fetoprotein serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82106,Alpha-fetoprotein amniotic,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82107,Alpha-fetoprotein l3,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82108,Assay of aluminum,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82120,Amines vaginal fluid qual,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82127,Amino acid single qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82128,Amino acids mult qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82131,Amino acids single quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82135,Assay aminolevulinic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82136,Amino acids quant 2-5,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82139,Amino acids quan 6 or more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82140,Assay of ammonia,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82143,Amniotic fluid scan,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82150,Assay of amylase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82154,Androstanediol glucuronide,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82157,Assay of androstenedione,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82160,Assay of androsterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82163,Assay of angiotensin ii,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82164,Angiotensin i enzyme test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82172,Assay of apolipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82175,Assay of arsenic,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82180,Assay of ascorbic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82190,Atomic absorption,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82232,Assay of beta-2 protein,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82239,Bile acids total,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82240,Bile acids cholylglycine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82247,Bilirubin total,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82248,Bilirubin direct,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82252,Fecal bilirubin test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82261,Assay of biotinidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82270,Occult blood feces,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82271,Occult blood other sources,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82272,Occult bld feces 1-3 tests,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82274,Assay test for blood fecal,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82286,Assay of bradykinin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82300,Assay of cadmium,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82306,Vitamin d 25 hydroxy,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82308,Assay of calcitonin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82310,Assay of calcium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82330,Assay of calcium,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82331,Calcium infusion test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82340,Assay of calcium in urine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82355,Calculus analysis qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82360,Calculus assay quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82365,Calculus spectroscopy,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82370,X-ray assay calculus,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82373,Assay c-d transfer measure,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82374,Assay blood carbon dioxide,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82375,Assay carboxyhb quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82376,Assay carboxyhb qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82378,Carcinoembryonic antigen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82379,Assay of carnitine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82380,Assay of carotene,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82382,Assay urine catecholamines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82383,Assay blood catecholamines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82384,Assay three catecholamines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82387,Assay of cathepsin-d,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82390,Assay of ceruloplasmin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82397,Chemiluminescent assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82415,Assay of chloramphenicol,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82435,Assay of blood chloride,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82436,Assay of urine chloride,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82438,Assay other fluid chlorides,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82441,Test for chlorohydrocarbons,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82465,Assay bld/serum cholesterol,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82480,Assay serum cholinesterase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82482,Assay rbc cholinesterase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82485,Assay chondroitin sulfate,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82486,Gas/liquid chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82487,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82488,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82489,Thin layer chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82491,Chromotography quant sing,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82492,Chromotography quant mult,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82495,Assay of chromium,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82507,Assay of citrate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82523,Collagen crosslinks,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82525,Assay of copper,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82528,Assay of corticosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82530,Cortisol free,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82533,Total cortisol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82540,Assay of creatine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82541,Column chromotography qual,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82542,Col chromotography qual/quan,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82543,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82544,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82550,Assay of ck (cpk),Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82552,Assay of cpk in blood,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82553,Creatine mb fraction,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82554,Creatine isoforms,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82565,Assay of creatinine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82570,Assay of urine creatinine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82575,Creatinine clearance test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82585,Assay of cryofibrinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82595,Assay of cryoglobulin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82600,Assay of cyanide,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82607,Vitamin b-12,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82608,B-12 binding capacity,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82610,Cystatin c,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82615,Test for urine cystines,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82626,Dehydroepiandrosterone,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82627,Dehydroepiandrosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82633,Desoxycorticosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82634,Deoxycortisol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82638,Assay of dibucaine number,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82642,Dihydrotestosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82652,Vit d 1 25-dihydroxy,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82656,Pancreatic elastase fecal,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82657,Enzyme cell activity,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82658,Enzyme cell activity ra,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82664,Electrophoretic test,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82668,Assay of erythropoietin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82670,Assay of total estradiol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82671,Assay of estrogens,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82672,Assay of estrogen,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82677,Assay of estriol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82679,Assay of estrone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82681,Assay dir meas fr estradiol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82693,Assay of ethylene glycol,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82696,Assay of etiocholanolone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82705,Fats/lipids feces qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82710,Fats/lipids feces quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82715,Assay of fecal fat,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82725,Assay of blood fatty acids,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82726,Long chain fatty acids,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82728,Assay of ferritin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82731,Assay of fetal fibronectin,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82735,Assay of fluoride,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82746,Assay of folic acid serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82747,Assay of folic acid rbc,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82757,Assay of semen fructose,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82759,Assay of rbc galactokinase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82760,Assay of galactose,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82775,Assay galactose transferase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82776,Galactose transferase test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82777,Galectin-3,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82784,Assay iga/igd/igg/igm each,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82785,Assay of ige,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82787,Igg 1 2 3 or 4 each,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82800,Blood ph,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82803,Blood gases any combination,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82805,Blood gases w/o2 saturation,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82810,Blood gases o2 sat only,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82820,Hemoglobin-oxygen affinity,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82930,Gastric analy w/ph ea spec,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82938,Gastrin test,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82941,Assay of gastrin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82943,Assay of glucagon,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82945,Glucose other fluid,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82946,Glucagon tolerance test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82947,Assay glucose blood quant,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82948,Reagent strip/blood glucose,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82950,Glucose test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82951,Glucose tolerance test (gtt),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82952,Gtt-added samples,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82955,Assay of g6pd enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82960,Test for g6pd enzyme,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82962,Glucose blood test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82963,Assay of glucosidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82965,Assay of gdh enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82977,Assay of ggt,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82978,Assay of glutathione,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82979,Assay rbc glutathione,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,82985,Assay of glycated protein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83001,Assay of gonadotropin (fsh),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83002,Assay of gonadotropin (lh),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83003,Assay growth hormone (hgh),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83006,Growth stimulation gene 2,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83009,H pylori (c-13) blood,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83010,Assay of haptoglobin quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83012,Assay of haptoglobins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83013,H pylori (c-13) breath,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83014,H pylori drug admin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83015,Heavy metal qual any anal,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83018,Heavy metal quant each nes,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83020,Hemoglobin electrophoresis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83021,Hemoglobin chromotography,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83026,Hemoglobin copper sulfate,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83030,Fetal hemoglobin chemical,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83033,Fetal hemoglobin assay qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83036,Glycosylated hemoglobin test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83037,Glycosylated hb home device,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83045,Blood methemoglobin test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83050,Blood methemoglobin assay,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83051,Assay of plasma hemoglobin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83060,Blood sulfhemoglobin assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83065,Assay of hemoglobin heat,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83068,Hemoglobin stability screen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83069,Assay of urine hemoglobin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83070,Assay of hemosiderin qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83080,Assay of b hexosaminidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83088,Assay of histamine,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83090,Assay of homocystine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83150,Assay of homovanillic acid,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83491,Assay of corticosteroids 17,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83497,Assay of 5-hiaa,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83498,Assay of progesterone 17-d,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83499,Assay of progesterone 20-,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83500,Assay free hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83505,Assay total hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83516,Immunoassay nonantibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83518,Immunoassay dipstick,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83519,Ria nonantibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83520,Immunoassay quant nos nonab,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83525,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83527,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83528,Assay of intrinsic factor,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83540,Assay of iron,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83550,Iron binding test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83570,Assay of idh enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83582,Assay of ketogenic steroids,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83586,Assay 17- ketosteroids,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83593,Fractionation ketosteroids,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83605,Assay of lactic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83615,Lactate (ld) (ldh) enzyme,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83625,Assay of ldh enzymes,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83630,Lactoferrin fecal (qual),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83631,Lactoferrin fecal (quant),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83632,Placental lactogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83633,Test urine for lactose,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83655,Assay of lead,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83661,L/s ratio fetal lung,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83662,Foam stability fetal lung,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83663,Fluoro polarize fetal lung,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83664,Lamellar bdy fetal lung,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83670,Assay of lap enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83690,Assay of lipase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83695,Assay of lipoprotein(a),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83698,Assay lipoprotein pla2,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83700,Lipopro bld electrophoretic,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83701,Lipoprotein bld hr fraction,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83704,Lipoprotein bld quan part,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83718,Assay of lipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83719,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83721,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83722,Lipoprtn dir meas sd ldl chl,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83727,Assay of lrh hormone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83735,Assay of magnesium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83775,Assay malate dehydrogenase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83785,Assay of manganese,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83788,Mass spectrometry qual,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83789,Mass spectrometry qual/quan,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83825,Assay of mercury,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83835,Assay of metanephrines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83857,Assay of methemalbumin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83861,Microfluid analy tears,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83864,Mucopolysaccharides,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83872,Assay synovial fluid mucin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83873,Assay of csf protein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83874,Assay of myoglobin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83876,Assay myeloperoxidase,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83880,Assay of natriuretic peptide,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83883,Assay nephelometry not spec,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83885,Assay of nickel,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83915,Assay of nucleotidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83916,Oligoclonal bands,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83918,Organic acids total quant,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83919,Organic acids qual each,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83921,Organic acid single quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83930,Assay of blood osmolality,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83935,Assay of urine osmolality,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83937,Assay of osteocalcin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83945,Assay of oxalate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83950,Oncoprotein her-2/neu,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83951,Oncoprotein dcp,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83970,Assay of parathormone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83986,Assay ph body fluid nos,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83987,Exhaled breath condensate,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83992,Assay for phencyclidine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,83993,Assay for calprotectin fecal,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84030,Assay of blood pku,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84035,Assay of phenylketones,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84060,Assay acid phosphatase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84061,Phosphatase forensic exam,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84066,Assay prostate phosphatase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84075,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84078,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84080,Assay alkaline phosphatases,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84081,Assay phosphatidylglycerol,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84085,Assay of rbc pg6d enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84087,Assay phosphohexose enzymes,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84100,Assay of phosphorus,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84105,Assay of urine phosphorus,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84106,Test for porphobilinogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84110,Assay of porphobilinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84112,Eval amniotic fluid protein,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84119,Test urine for porphyrins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84120,Assay of urine porphyrins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84126,Assay of feces porphyrins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84132,Assay of serum potassium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84133,Assay of urine potassium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84134,Assay of prealbumin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84135,Assay of pregnanediol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84138,Assay of pregnanetriol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84140,Assay of pregnenolone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84143,Assay of 17-hydroxypregneno,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84144,Assay of progesterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84145,Procalcitonin (pct),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84146,Assay of prolactin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84150,Assay of prostaglandin,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84152,Assay of psa complexed,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84153,Assay of psa total,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84154,Assay of psa free,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84155,Assay of protein serum,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84156,Assay of protein urine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84157,Assay of protein other,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84160,Assay of protein any source,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84163,Pappa serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84165,Protein e-phoresis serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84166,Protein e-phoresis/urine/csf,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84181,Western blot test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84182,Protein western blot test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84202,Assay rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84203,Test rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84206,Assay of proinsulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84207,Assay of vitamin b-6,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84210,Assay of pyruvate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84220,Assay of pyruvate kinase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84228,Assay of quinine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84233,Assay of estrogen,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84234,Assay of progesterone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84235,Assay of endocrine hormone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84238,Assay nonendocrine receptor,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84244,Assay of renin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84252,Assay of vitamin b-2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84255,Assay of selenium,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84260,Assay of serotonin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84270,Assay of sex hormone globul,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84275,Assay of sialic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84285,Assay of silica,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84295,Assay of serum sodium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84300,Assay of urine sodium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84302,Assay of sweat sodium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84305,Assay of somatomedin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84307,Assay of somatostatin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84311,Spectrophotometry,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84315,Body fluid specific gravity,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84375,Chromatogram assay sugars,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84376,Sugars single qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84377,Sugars multiple qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84378,Sugars single quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84379,Sugars multiple quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84392,Assay of urine sulfate,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84402,Assay of free testosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84403,Assay of total testosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84410,Testosterone bioavailable,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84425,Assay of vitamin b-1,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84430,Assay of thiocyanate,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84431,Thromboxane urine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84432,Assay of thyroglobulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84436,Assay of total thyroxine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84437,Assay of neonatal thyroxine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84439,Assay of free thyroxine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84442,Assay of thyroid activity,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84443,Assay thyroid stim hormone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84445,Assay of tsi globulin,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84446,Assay of vitamin e,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84449,Assay of transcortin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84450,Transferase (ast) (sgot),Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84460,Alanine amino (alt) (sgpt),Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84466,Assay of transferrin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84478,Assay of triglycerides,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84479,Assay of thyroid (t3 or t4),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84480,Assay triiodothyronine (t3),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84481,Free assay (ft-3),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84482,T3 reverse,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84484,Assay of troponin quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84485,Assay duodenal fluid trypsin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84488,Test feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84490,Assay of feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84510,Assay of tyrosine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84512,Assay of troponin qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84520,Assay of urea nitrogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84525,Urea nitrogen semi-quant,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84540,Assay of urine/urea-n,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84545,Urea-n clearance test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84550,Assay of blood/uric acid,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84560,Assay of urine/uric acid,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84577,Assay of feces/urobilinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84578,Test urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84580,Assay of urine urobilinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84583,Assay of urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84585,Assay of urine vma,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84586,Assay of vip,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84588,Assay of vasopressin,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84590,Assay of vitamin a,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84591,Assay of nos vitamin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84597,Assay of vitamin k,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84600,Assay of volatiles,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84620,Xylose tolerance test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84630,Assay of zinc,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84681,Assay of c-peptide,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84702,Chorionic gonadotropin test,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84703,Chorionic gonadotropin assay,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84704,Hcg free betachain test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84830,Ovulation tests,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,84999,Clinical chemistry test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85002,Bleeding time test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85004,Automated diff wbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85007,Bl smear w/diff wbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85008,Bl smear w/o diff wbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85009,Manual diff wbc count b-coat,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85013,Spun microhematocrit,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85014,Hematocrit,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85018,Hemoglobin,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85025,Complete cbc w/auto diff wbc,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85027,Complete cbc automated,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85032,Manual cell count each,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85041,Automated rbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85044,Manual reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85045,Automated reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85046,Reticyte/hgb concentrate,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85048,Automated leukocyte count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85049,Automated platelet count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85055,Reticulated platelet assay,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85060,Blood smear interpretation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85097,Bone marrow interpretation,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85130,Chromogenic substrate assay,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85170,Blood clot retraction,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85175,Blood clot lysis time,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85210,Clot factor ii prothrom spec,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85220,Blooc clot factor v test,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85230,Clot factor vii proconvertin,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85240,Clot factor viii ahg 1 stage,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85244,Clot factor viii reltd antgn,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85245,Clot factor viii vw ristoctn,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85246,Clot factor viii vw antigen,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85247,Clot factor viii multimetric,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85250,Clot factor ix ptc/chrstmas,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85260,Clot factor x stuart-power,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85270,Clot factor xi pta,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85280,Clot factor xii hageman,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85290,Clot factor xiii fibrin stab,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85291,Clot factor xiii fibrin scrn,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85292,Clot factor fletcher fact,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85293,Clot factor wght kininogen,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85300,Antithrombin iii activity,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85301,Antithrombin iii antigen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85302,Clot inhibit prot c antigen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85303,Clot inhibit prot c activity,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85305,Clot inhibit prot s total,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85306,Clot inhibit prot s free,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85307,Assay activated protein c,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85335,Factor inhibitor test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85337,Thrombomodulin,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85345,Coagulation time lee & white,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85347,Coagulation time activated,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85348,Coagulation time otr method,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85360,Euglobulin lysis,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85362,Fibrin degradation products,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85366,Fibrinogen test,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85370,Fibrinogen test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85378,Fibrin degrade semiquant,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85379,Fibrin degradation quant,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85380,Fibrin degradj d-dimer,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85384,Fibrinogen activity,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85385,Fibrinogen antigen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85390,Fibrinolysins screen i&r,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85396,Clotting assay whole blood,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85397,Clotting funct activity,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85400,Fibrinolytic plasmin,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85410,Fibrinolytic antiplasmin,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85415,Fibrinolytic plasminogen,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85420,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85421,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85441,Heinz bodies direct,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85445,Heinz bodies induced,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85460,Hemoglobin fetal,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85461,Hemoglobin fetal,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85475,Hemolysin acid,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85520,Heparin assay,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85525,Heparin neutralization,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85530,Heparin-protamine tolerance,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85536,Iron stain peripheral blood,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85540,Wbc alkaline phosphatase,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85547,Rbc mechanical fragility,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85549,Muramidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85555,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85557,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85576,Blood platelet aggregation,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85597,Phospholipid pltlt neutraliz,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85598,Hexagnal phosph pltlt neutrl,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85610,Prothrombin time,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85611,Prothrombin test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85612,Viper venom prothrombin time,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85613,Russell viper venom diluted,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85635,Reptilase test,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85651,Rbc sed rate nonautomated,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85652,Rbc sed rate automated,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85660,Rbc sickle cell test,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85670,Thrombin time plasma,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85675,Thrombin time titer,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85705,Thromboplastin inhibition,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85730,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85732,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85810,Blood viscosity examination,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,85999,Hematology procedure,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86000,Agglutinins febrile antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86001,Allergen specific igg,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86003,Allg spec ige crude xtrc ea,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86005,Allg spec ige multiallg scr,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86008,Allg spec ige recomb ea,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86021,Wbc antibody identification,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86022,Platelet antibodies,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86023,Immunoglobulin assay,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86038,Antinuclear antibodies,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86039,Antinuclear antibodies (ana),Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86060,Antistreptolysin o titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86063,Antistreptolysin o screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86140,C-reactive protein,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86141,C-reactive protein hs,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86146,Beta-2 glycoprotein antibody,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86147,Cardiolipin antibody ea ig,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86148,Anti-phospholipid antibody,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86152,Cell enumeration & id,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86153,Cell enumeration phys interp,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86155,Chemotaxis assay,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86156,Cold agglutinin screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86157,Cold agglutinin titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86160,Complement antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86161,Complement/function activity,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86162,Complement total (ch50),Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86171,Complement fixation each,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86185,Counterimmunoelectrophoresis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86200,Ccp antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86215,Deoxyribonuclease antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86225,Dna antibody native,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86226,Dna antibody single strand,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86235,Nuclear antigen antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86243,Fc receptor,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86255,Fluorescent antibody screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86256,Fluorescent antibody titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86277,Growth hormone antibody,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86280,Hemagglutination inhibition,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86294,Immunoassay tumor qual,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86300,Immunoassay tumor ca 15-3,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86301,Immunoassay tumor ca 19-9,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86304,Immunoassay tumor ca 125,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86305,Human epididymis protein 4,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86308,Heterophile antibody screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86309,Heterophile antibody titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86310,Heterophile antibody absrbj,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86316,Immunoassay tumor other,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86317,Immunoassay infectious agent,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86318,Ia infectious agent antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86320,Serum immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86325,Other immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86327,Immunoelectrophoresis assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86328,Ia nfct ab sarscov2 covid19,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86329,Immunodiffusion nes,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86331,Immunodiffusion ouchterlony,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86332,Immune complex assay,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86334,Immunofix e-phoresis serum,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86335,Immunfix e-phorsis/urine/csf,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86336,Inhibin a,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86337,Insulin antibodies,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86340,Intrinsic factor antibody,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86341,Islet cell antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86343,Leukocyte histamine release,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86344,Leukocyte phagocytosis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86352,Cell function assay w/stim,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86353,Lymphocyte transformation,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86355,B cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86356,Mononuclear cell antigen,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86357,Nk cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86359,T cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86360,T cell absolute count/ratio,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86361,T cell absolute count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86367,Stem cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86376,Microsomal antibody each,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86378,Migration inhibitory factor,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86382,Neutralization test viral,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86384,Nitroblue tetrazolium dye,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86386,Nuclear matrix protein 22,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86403,Particle agglut antbdy scrn,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86406,Particle agglut antbdy titr,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86408,Neutrlzg antb sarscov2 scr,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86409,Neutrlzg antb sarscov2 titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86413,Sars-cov-2 antb quantitative,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86430,Rheumatoid factor test qual,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86431,Rheumatoid factor quant,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86480,Tb test cell immun measure,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86481,Tb ag response t-cell susp,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86485,Skin test candida,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86486,Skin test nos antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86490,Coccidioidomycosis skin test,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86510,Histoplasmosis skin test,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86580,Tb intradermal test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86590,Streptokinase antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86592,Syphilis test non-trep qual,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86593,Syphilis test non-trep quant,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86602,Antinomyces antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86603,Adenovirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86606,Aspergillus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86609,Bacterium antibody,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86611,Bartonella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86612,Blastomyces antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86615,Bordetella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86617,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86618,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86619,Borrelia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86622,Brucella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86625,Campylobacter antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86628,Candida antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86631,Chlamydia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86632,Chlamydia igm antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86635,Coccidioides antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86638,Q fever antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86641,Cryptococcus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86644,Cmv antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86645,Cmv antibody igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86648,Diphtheria antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86651,Encephalitis californ antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86652,Encephaltis east eqne anbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86653,Encephaltis st louis antbody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86654,Encephaltis west eqne antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86658,Enterovirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86663,Epstein-barr antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86664,Epstein-barr nuclear antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86665,Epstein-barr capsid vca,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86666,Ehrlichia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86668,Francisella tularensis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86671,Fungus nes antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86674,Giardia lamblia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86677,Helicobacter pylori antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86682,Helminth antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86684,Hemophilus influenza antibdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86687,Htlv-i antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86688,Htlv-ii antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86689,Htlv/hiv confirmj antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86692,Hepatitis delta agent antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86694,Herpes simplex nes antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86695,Herpes simplex type 1 test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86696,Herpes simplex type 2 test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86698,Histoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86701,Hiv-1antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86702,Hiv-2 antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86704,Hep b core antibody total,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86705,Hep b core antibody igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86706,Hep b surface antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86707,Hepatitis be antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86708,Hepatitis a antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86709,Hepatitis a igm antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86710,Influenza virus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86711,John cunningham antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86713,Legionella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86717,Leishmania antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86720,Leptospira antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86723,Listeria monocytogenes,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86727,Lymph choriomeningitis ab,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86729,Lympho venereum antibody,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86732,Mucormycosis antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86735,Mumps antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86738,Mycoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86741,Neisseria meningitidis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86744,Nocardia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86747,Parvovirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86750,Malaria antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86753,Protozoa antibody nos,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86756,Respiratory virus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86757,Rickettsia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86759,Rotavirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86762,Rubella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86765,Rubeola antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86768,Salmonella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86769,Sars-cov-2 covid-19 antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86771,Shigella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86774,Tetanus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86777,Toxoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86778,Toxoplasma antibody igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86780,Treponema pallidum,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86784,Trichinella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86787,Varicella-zoster antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86788,West nile virus ab igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86789,West nile virus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86790,Virus antibody nos,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86793,Yersinia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86794,Zika virus igm antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86800,Thyroglobulin antibody,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86803,Hepatitis c ab test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86804,Hep c ab test confirm,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86805,Lymphocytotoxicity assay,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86806,Lymphocytotoxicity assay,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86807,Cytotoxic antibody screening,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86808,Cytotoxic antibody screening,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86812,Hla typing a b or c,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86813,Hla typing a b or c,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86816,Hla typing dr/dq,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86817,Hla typing dr/dq,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86821,Lymphocyte culture mixed,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86822,Lymphocyte culture primed,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86825,Hla x-math non-cytotoxic,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86826,Hla x-match noncytotoxc addl,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86828,Hla class i&ii antibody qual,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86829,Hla class i/ii antibody qual,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86830,Hla class i phenotype qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86831,Hla class ii phenotype qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86832,Hla class i high defin qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86833,Hla class ii high defin qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86834,Hla class i semiquant panel,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86835,Hla class ii semiquant panel,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86849,Immunology procedure,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86850,Rbc antibody screen,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86860,Rbc antibody elution,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86870,Rbc antibody identification,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86880,Coombs test direct,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86885,Coombs test indirect qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86886,Coombs test indirect titer,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86900,Blood typing serologic abo,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86901,Blood typing serologic rh(d),Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86902,Blood type antigen donor ea,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86904,Blood typing patient serum,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86905,Blood typing rbc antigens,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86906,Bld typing serologic rh phnt,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86910,Blood typing paternity test,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86911,Blood typing antigen system,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86920,Compatibility test spin,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86921,Compatibility test incubate,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86922,Compatibility test antiglob,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86923,Compatibility test electric,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86940,Hemolysins/agglutinins auto,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86941,Hemolysins/agglutinins,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,86999,Transfusion procedure,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87003,Small animal inoculation,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87015,Specimen infect agnt concntj,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87040,Blood culture for bacteria,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87045,Feces culture aerobic bact,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87046,Stool cultr aerobic bact ea,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87070,Culture othr specimn aerobic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87071,Culture aerobic quant other,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87073,Culture bacteria anaerobic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87075,Cultr bacteria except blood,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87076,Culture anaerobe ident each,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87077,Culture aerobic identify,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87081,Culture screen only,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87084,Culture of specimen by kit,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87086,Urine culture/colony count,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87088,Urine bacteria culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87101,Skin fungi culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87102,Fungus isolation culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87103,Blood fungus culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87106,Fungi identification yeast,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87107,Fungi identification mold,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87109,Mycoplasma,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87110,Chlamydia culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87116,Mycobacteria culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87118,Mycobacteric identification,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87140,Culture type immunofluoresc,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87143,Culture typing glc/hplc,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87147,Culture type immunologic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87149,Dna/rna direct probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87150,Dna/rna amplified probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87152,Culture type pulse field gel,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87158,Culture typing added method,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87164,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87166,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87168,Macroscopic exam arthropod,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87169,Macroscopic exam parasite,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87172,Pinworm exam,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87176,Tissue homogenization cultr,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87177,Ova and parasites smears,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87181,Microbe susceptible diffuse,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87184,Microbe susceptible disk,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87185,Microbe susceptible enzyme,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87186,Microbe susceptible mic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87187,Microbe susceptible mlc,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87188,Microbe suscept macrobroth,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87190,Microbe suscept mycobacteri,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87197,Bactericidal level serum,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87205,Smear gram stain,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87206,Smear fluorescent/acid stai,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87207,Smear special stain,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87209,Smear complex stain,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87210,Smear wet mount saline/ink,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87220,Tissue exam for fungi,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87230,Assay toxin or antitoxin,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87250,Virus inoculate eggs/animal,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87252,Virus inoculation tissue,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87253,Virus inoculate tissue addl,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87254,Virus inoculation shell via,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87255,Genet virus isolate hsv,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87260,Adenovirus ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87265,Pertussis ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87267,Enterovirus antibody dfa,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87269,Giardia ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87270,Chlamydia trachomatis ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87271,Cytomegalovirus dfa,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87272,Cryptosporidium ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87273,Herpes simplex 2 ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87274,Herpes simplex 1 ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87275,Influenza b ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87276,Influenza a ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87277,Legionella micdadei ag if,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87278,Legion pneumophilia ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87279,Parainfluenza ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87280,Respiratory syncytial ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87281,Pneumocystis carinii ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87283,Rubeola ag if,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87285,Treponema pallidum ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87290,Varicella zoster ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87299,Antibody detection nos if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87300,Ag detection polyval if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87301,Adenovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87305,Aspergillus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87320,Chylmd trach ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87324,Clostridium ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87327,Cryptococcus neoform ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87328,Cryptosporidium ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87329,Giardia ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87332,Cytomegalovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87335,E coli 0157 ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87336,Entamoeb hist dispr ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87337,Entamoeb hist group ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87338,Hpylori stool ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87339,H pylori ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87340,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87341,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87350,Hepatitis be ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87380,Hepatitis delta agent ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87385,Histoplasma capsul ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87390,Hiv-1 ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87391,Hiv-2 ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87400,Influenza a/b each ag ia,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87420,Resp syncytial virus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87425,Rotavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87426,Sarscov coronavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87427,Shiga-like toxin ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87428,Sarscov & inf vir a&b ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87430,Strep a ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87449,Nos each organism ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87450,Ag detect nos ia single,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87451,Polyvalent mult org ea ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87470,Bartonella dna dir probe,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87471,Bartonella dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87472,Bartonella dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87475,Lyme dis dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87476,Lyme dis dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87477,Lyme dis dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87480,Candida dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87481,Candida dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87482,Candida dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87485,Chylmd pneum dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87486,Chylmd pneum dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87487,Chylmd pneum dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87490,Chylmd trach dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87491,Chylmd trach dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87492,Chylmd trach dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87493,C diff amplified probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87495,Cytomeg dna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87496,Cytomeg dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87497,Cytomeg dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87498,Enterovirus probe&revrs trns,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87500,Vanomycin dna amp probe,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87501,Influenza dna amp prob 1+,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87502,Influenza dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87503,Influenza dna amp prob addl,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87510,Gardner vag dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87511,Gardner vag dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87512,Gardner vag dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87515,Hepatitis b dna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87516,Hepatitis b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87517,Hepatitis b dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87520,Hepatitis c rna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87521,Hepatitis c probe&rvrs trnsc,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87522,Hepatitis c revrs trnscrpj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87525,Hepatitis g dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87526,Hepatitis g dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87527,Hepatitis g dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87528,Hsv dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87529,Hsv dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87530,Hsv dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87531,Hhv-6 dna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87532,Hhv-6 dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87533,Hhv-6 dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87534,Hiv-1 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87535,Hiv-1 probe&reverse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87536,Hiv-1 quant&revrse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87537,Hiv-2 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87538,Hiv-2 probe&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87539,Hiv-2 quant&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87540,Legion pneumo dna dir prob,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87541,Legion pneumo dna amp prob,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87542,Legion pneumo dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87550,Mycobacteria dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87551,Mycobacteria dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87552,Mycobacteria dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87555,M.tuberculo dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87556,M.tuberculo dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87557,M.tuberculo dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87560,M.avium-intra dna dir prob,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87561,M.avium-intra dna amp prob,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87562,M.avium-intra dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87563,M. genitalium amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87580,M.pneumon dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87581,M.pneumon dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87590,N.gonorrhoeae dna dir prob,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87591,N.gonorrhoeae dna amp prob,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87592,N.gonorrhoeae dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87623,Hpv low-risk types,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87624,Hpv high-risk types,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87625,Hpv types 16 & 18 only,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87634,Rsv dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87635,Sars-cov-2 covid-19 amp prb,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87636,Sarscov2 & inf a&b amp prb,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87640,Staph a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87641,Mr-staph dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87650,Strep a dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87651,Strep a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87652,Strep a dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87653,Strep b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87660,Trichomonas vagin dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87661,Trichomonas vaginalis amplif,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87662,Zika virus dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87797,Detect agent nos dna dir,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87798,Detect agent nos dna amp,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87799,Detect agent nos dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87800,Detect agnt mult dna direc,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87801,Detect agnt mult dna ampli,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87802,Strep b assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87803,Clostridium toxin a w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87804,Influenza assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87806,Hiv w/hiv1&2 antb w/optic,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87807,Rsv assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87808,Trichomonas assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87809,Adenovirus assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87810,Chylmd trach assay w/optic,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87811,Sars-cov-2 covid19 w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87850,N. gonorrhoeae assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87880,Strep a assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87899,Agent nos assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87904,Phenotype dna hiv w/clt add,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87905,Sialidase enzyme assay,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,87999,Microbiology procedure,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88104,Cytopath fl nongyn smears,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88106,Cytopath fl nongyn filter,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88108,Cytopath concentrate tech,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88112,Cytopath cell enhance tech,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88120,Cytp urne 3-5 probes ea spec,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88125,Forensic cytopathology,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88130,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88140,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88141,Cytopath c/v interpret,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88142,Cytopath c/v thin layer,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88143,Cytopath c/v thin layer redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88147,Cytopath c/v automated,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88148,Cytopath c/v auto rescreen,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88150,Cytopath c/v manual,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88152,Cytopath c/v auto redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88153,Cytopath c/v redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88154,Cytopath c/v select,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88155,Cytopath c/v index add-on,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88160,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88161,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88162,Cytopath smear other source,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88164,Cytopath tbs c/v manual,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88165,Cytopath tbs c/v redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88166,Cytopath tbs c/v auto redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88167,Cytopath tbs c/v select,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88172,Cytp dx eval fna 1st ea site,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88173,Cytopath eval fna report,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88174,Cytopath c/v auto in fluid,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88175,Cytopath c/v auto fluid redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88177,Cytp fna eval ea addl,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88182,Cell marker study,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88184,Flowcytometry/ tc 1 marker,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88187,Flowcytometry/read 2-8,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88188,Flowcytometry/read 9-15,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88189,Flowcytometry/read 16 & >,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88199,Cytopathology procedure,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88240,Cell cryopreserve/storage,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88241,Frozen cell preparation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88245,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88248,Chromosome analysis 50-100,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88249,Chromosome analysis 100,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88261,Chromosome analysis 5,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88262,Chromosome analysis 15-20,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88263,Chromosome analysis 45,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88264,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88267,Chromosome analys placenta,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88269,Chromosome analys amniotic,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88271,Cytogenetics dna probe,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88272,Cytogenetics 3-5,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88273,Cytogenetics 10-30,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88274,Cytogenetics 25-99,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88275,Cytogenetics 100-300,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88280,Chromosome karyotype study,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88283,Chromosome banding study,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88285,Chromosome count additional,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88289,Chromosome study additional,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88291,Cyto/molecular report,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88299,Cytogenetic study,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88300,Surgical path gross,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88302,Tissue exam by pathologist,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88304,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88305,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88311,Decalcify tissue,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88312,Special stains group 1,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88313,Special stains group 2,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88314,Histochemical stains add-on,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88321,Microslide consultation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88323,Microslide consultation,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88325,Comprehensive review of data,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88329,Path consult introp,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88331,Path consult intraop 1 bloc,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88332,Path consult intraop addl,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88333,Intraop cyto path consult 1,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88334,Intraop cyto path consult 2,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88342,Immunohisto antb 1st stain,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88346,Immunofluor antb 1st stain,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88347,Immunofluorescent study,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88355,Analysis skeletal muscle,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88356,Analysis nerve,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88358,Analysis tumor,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88363,Xm archive tissue molec anal,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88364,Insitu hybridization (fish),Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88369,M/phmtrc alysishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88371,Protein western blot tissue,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88372,Protein analysis w/probe,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88373,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88374,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88375,Optical endomicroscpy interp,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88377,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88380,Microdissection laser,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88381,Microdissection manual,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88387,Tiss exam molecular study,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88388,Tiss ex molecul study add-on,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88399,Surgical pathology procedure,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88720,Bilirubin total transcut,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88738,Hgb quant transcutaneous,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88740,Transcutaneous carboxyhb,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88741,Transcutaneous methb,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,88749,In vivo lab service,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89050,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89051,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89055,Leukocyte assessment fecal,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89060,Exam synovial fluid crystals,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89125,Specimen fat stain,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89160,Exam feces for meat fibers,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89190,Nasal smear for eosinophils,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89220,Sputum specimen collection,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89230,Collect sweat for test,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89240,Pathology lab procedure,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89250,Cultr oocyte/embryo <4 days,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89253,Embryo hatching,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89254,Oocyte identification,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89255,Prepare embryo for transfer,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89257,Sperm identification,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89260,Sperm isolation simple,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89261,Sperm isolation complex,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89264,Identify sperm tissue,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89281,Assist oocyte fertilization,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89290,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89291,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89300,Semen analysis w/huhner,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89310,Semen analysis w/count,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89320,Semen anal vol/count/mot,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89321,Semen anal sperm detection,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89322,Semen anal strict criteria,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89325,Sperm antibody test,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89329,Sperm evaluation test,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89330,Evaluation cervical mucus,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89331,Retrograde ejaculation anal,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89335,Cryopreserve testicular tiss,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89353,Thawing cryopresrved sperm,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,89398,Unlisted reprod med lab proc,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90287,Botulinum antitoxin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90288,Botulism ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,90291,Cmv ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,90371,Hep b ig im,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90375,Rabies ig im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90376,Rabies ig heat treated,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90377,Rabies ig ht&sol human im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90378,Rsv mab im 50mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90384,Rh ig full-dose im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90386,Rh ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,90389,Tetanus ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90393,Vaccina ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90396,Varicella-zoster ig im,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90460,Im admin 1st/only component,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90461,Im admin each addl component,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90471,Immunization admin,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90472,Immunization admin each add,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90473,Immune admin oral/nasal,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90474,Immune admin oral/nasal addl,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90476,Adenovirus vaccine type 4,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90477,Adenovirus vaccine type 7,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90581,Anthrax vaccine sc or im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90585,Bcg vaccine percut,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90586,Bcg vaccine intravesical,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90587,Dengue vacc quad 3 dose subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90619,Menacwy-tt vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90620,Menb-4c vacc 2 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90621,Menb-fhbp vacc 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90625,Cholera vaccine live oral,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90630,Flu vacc iiv4 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90632,Hepa vaccine adult im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90633,Hepa vacc ped/adol 2 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90634,Hepa vacc ped/adol 3 dose,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90636,Hep a/hep b vacc adult im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90644,Hib-mency vacc 6wk-18m0 im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90645,Hib vaccine hboc im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90646,Hib vaccine prp-d im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90647,Hib prp-omp vacc 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90648,Hib prp-t vaccine 4 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90649,4vhpv vaccine 3 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90650,2vhpv vaccine 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90651,9vhpv vaccine 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90653,Iiv adjuvant vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90654,Flu vacc iiv3 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90658,Iiv3 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90660,Laiv3 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90662,Iiv no prsv increased ag im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90664,Laiv vacc pandemic intranasl,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90666,Flu vac pandem prsrv free im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90667,Iiv vacc pandemic adjuvt im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90668,Iiv vaccine pandemic im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90669,Pneumococcal vacc 7 val im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90670,Pcv13 vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90672,Laiv4 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90673,Riv3 vaccine no preserv im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90675,Rabies vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90676,Rabies vaccine id,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90680,Rv5 vacc 3 dose live oral,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90681,Rv1 vacc 2 dose live oral,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90682,Riv4 vacc recombinant dna im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90690,Typhoid vaccine oral,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90691,Typhoid vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90692,Typhoid vaccine h-p sc/id,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90693,Typhoid vaccine akd sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90696,Dtap-ipv vaccine 4-6 yrs im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90697,Dtap-ipv-hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90698,Dtap-ipv/hib vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90700,Dtap vaccine < 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90702,Dt vaccine under 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90703,Tetanus vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90704,Mumps vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90705,Measles vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90706,Rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90707,Mmr vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90708,Measles-rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90710,Mmrv vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90712,Oral poliovirus vaccine,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90713,Poliovirus ipv sc/im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90714,Td vacc no presv 7 yrs+ im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90715,Tdap vaccine 7 yrs/> im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90716,Var vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90717,Yellow fever vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90719,Diphtheria vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90720,Dtp/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90721,Dtap/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90723,Dtap-hep b-ipv vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90725,Cholera vaccine injectable,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90727,Plague vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90733,Mpsv4 vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90734,Menacwyd/menacwycrm vacc im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90735,Encephalitis vaccine sc,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90736,Hzv vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90738,Inactivated je vacc im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90739,Hepb vacc 2 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90740,Hepb vacc 3 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90743,Hepb vacc 2 dose adolesc im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90744,Hepb vacc 3 dose ped/adol im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90746,Hepb vaccine 3 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90747,Hepb vacc 4 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90748,Hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90749,Vaccine toxoid,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90750,Hzv vacc recombinant im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90756,Cciiv4 vacc abx free im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90785,Psytx complex interactive,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90791,Psych diagnostic evaluation,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90792,Psych diag eval w/med srvcs,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90832,Psytx w pt 30 minutes,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90833,Psytx w pt w e/m 30 min,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90834,Psytx w pt 45 minutes,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90836,Psytx w pt w e/m 45 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90837,Psytx w pt 60 minutes,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90838,Psytx w pt w e/m 60 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90839,Psytx crisis initial 60 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90840,Psytx crisis ea addl 30 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90845,Psychoanalysis,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90846,Family psytx w/o pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90847,Family psytx w/pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90849,Multiple family group psytx,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90853,Group psychotherapy,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90863,Pharmacologic mgmt w/psytx,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90865,Narcosynthesis,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90867,Tcranial magn stim tx plan,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90868,Tcranial magn stim tx deli,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90869,Tcran magn stim redetemine,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90870,Electroconvulsive therapy,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90875,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90876,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90880,Hypnotherapy,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90882,Environmental manipulation,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90885,Psy evaluation of records,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90887,Consultation with family,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90889,Preparation of report,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90899,Psychiatric service/therapy,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90901,Biofeedback train any meth,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90911,Biofeedback peri/uro/rectal,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90912,Bfb training 1st 15 min,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90913,Bfb training ea addl 15 min,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90935,Hemodialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90937,Hemodialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90940,Hemodialysis access study,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90945,Dialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90947,Dialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90989,Dialysis training complete,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90993,Dialysis training incompl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90997,Hemoperfusion,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,90999,Dialysis procedure,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91010,Esophagus motility study,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91013,Esophgl motil w/stim/perfus,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91020,Gastric motility studies,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91022,Duodenal motility study,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91030,Acid perfusion of esophagus,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91034,Gastroesophageal reflux test,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91035,G-esoph reflx tst w/electrod,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91037,Esoph imped function test,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91038,Esoph imped funct test > 1hr,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91040,Esoph balloon distension tst,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91110,Gi tract capsule endoscopy,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,91111,Esophageal capsule endoscopy,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91112,Gi wireless capsule measure,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91117,Colon motility 6 hr study,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91120,Rectal sensation test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91122,Anal pressure record,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91132,Electrogastrography,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91133,Electrogastrography w/test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91200,Liver elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91299,Gastroenterology procedure,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91302,Coronavirus vaccine 3,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91303,Coronavirus vaccine 4,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91304,Coronavirus vaccine 5,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91305,Coronavirus vaccine 6,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91306,Coronavirus vaccine 7,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91307,Coronavirus vaccine 8,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91308,Coronavirus vaccine 9,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91309,Coronavirus vaccine 10,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,91310,Coronavirus vaccine 11,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92015,Determine refractive state,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92018,New eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92019,Eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92020,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92025,Corneal topography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92060,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92065,Orthoptic/pleoptic training,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92071,Contact lens fitting for tx,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92072,Fit contac lens for managmnt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92081,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92082,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92083,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92100,Serial tonometry exam(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92132,Cmptr ophth dx img ant segmt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92133,Cmptr ophth img optic nerve,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92134,Cptr ophth dx img post segmt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92136,Ophthalmic biometry,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92140,Glaucoma provocative tests,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92145,Corneal hysteresis deter,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92201,Opscpy extnd rta draw uni/bi,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92202,Opscpy extnd on/mac draw,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92225,Special eye exam initial,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92226,Special eye exam subsequent,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92227,Img rta detcj/mntr ds staff,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92228,Img rta detc/mntr ds phy/qhp,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92229,Img rta detc/mntr ds poc aly,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92230,Eye exam with photos,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92235,Fluorescein angrph uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92240,Icg angiography uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92242,Fluorescein icg angiography,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92250,Eye exam with photos,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92260,Ophthalmoscopy/dynamometry,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92265,Eye muscle evaluation,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92270,Electro-oculography,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92273,Full field erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92274,Multifocal erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92275,Electroretinography,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92283,Color vision examination,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92284,Dark adaptation eye exam,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92285,Eye photography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92286,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92287,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92310,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92311,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92312,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92313,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92314,Prescription of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92315,Rx cntact lens aphakia 1 eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92316,Rx cntact lens aphakia 2 eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92317,Rx corneoscleral cntact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92325,Modification of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92326,Replacement of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92340,Fit spectacles monofocal,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92341,Fit spectacles bifocal,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92342,Fit spectacles multifocal,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92352,Fit aphakia spectcl monofocl,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92353,Fit aphakia spectcl multifoc,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92354,Fit spectacles single system,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92355,Fit spectacles compound lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92358,Aphakia prosth service temp,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92370,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92371,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92499,Eye service or procedure,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92507,Speech/hearing therapy,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92516,Facial nerve function test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92517,Vemp test i&r cervical,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92518,Vemp test i&r ocular,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92519,Vemp tst i&r cervical&ocular,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92520,Laryngeal function studies,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92521,Evaluation of speech fluency,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92522,Evaluate speech production,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92523,Speech sound lang comprehen,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92524,Behavral qualit analys voice,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92534,Optokinetic nystagmus test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92537,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92538,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92540,Basic vestibular evaluation,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92543,Caloric vestibular test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92546,Sinusoidal rotational test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92547,Supplemental electrical test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92548,Cdp-sot 6 cond w/i&r,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92550,Tympanometry & reflex thresh,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92553,Audiometry air & bone,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92557,Comprehensive hearing test,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92558,Evoked auditory test qual,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92570,Acoustic immitance testing,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92572,Staggered spondaic word test,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92577,Stenger test speech,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92579,Visual audiometry (vra),Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92582,Conditioning play audiometry,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92584,Electrocochleography,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92585,Auditor evoke potent compre,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92586,Auditor evoke potent limit,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92587,Evoked auditory test limited,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92588,Evoked auditory tst complete,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92597,Oral speech device eval,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92601,Cochlear implt f/up exam <7,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92602,Reprogram cochlear implt <7,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92603,Cochlear implt f/up exam 7/>,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92604,Reprogram cochlear implt 7/>,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92605,Ex for nonspeech device rx,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92606,Non-speech device service,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92607,Ex for speech device rx 1hr,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92608,Ex for speech device rx addl,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92610,Evaluate swallowing function,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92618,Ex for nonspeech dev rx add,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92620,Auditory function 60 min,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92621,Auditory function + 15 min,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92625,Tinnitus assessment,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92626,Eval aud funcj 1st hour,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92627,Eval aud funcj ea addl 15,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92630,Aud rehab pre-ling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92633,Aud rehab postling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92651,Aep hearing status deter i&r,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92652,Aep thrshld est mlt freq i&r,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92653,Aep neurodiagnostic i&r,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92920,Prq cardiac angioplast 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92921,Prq cardiac angio addl art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92924,Prq card angio/athrect 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92925,Prq card angio/athrect addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92928,Prq card stent w/angio 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92929,Prq card stent w/angio addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92933,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92934,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92937,Prq revasc byp graft 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92938,Prq revasc byp graft addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92941,Prq card revasc mi 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92943,Prq card revasc chronic 1vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92944,Prq card revasc chronic addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92950,Heart/lung resuscitation cpr,General Medicine,Per Unit,$385.17 ,OP,$385.17 ,$385.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92953,Temporary external pacing,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92960,Cardioversion electric ext,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92961,Cardioversion electric int,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92971,Cardioassist external,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92973,Prq coronary mech thrombect,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92975,Dissolve clot heart vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92977,Dissolve clot heart vessel,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92978,Endoluminl ivus oct c 1st,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92979,Endoluminl ivus oct c ea,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,92986,Revision of aortic valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92987,Revision of mitral valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92990,Revision of pulmonary valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92997,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,92998,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93000,Electrocardiogram complete,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93005,Electrocardiogram tracing,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93010,Electrocardiogram report,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93015,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93016,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93017,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93018,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93024,Cardiac drug stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93025,Microvolt t-wave assess,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93040,Rhythm ecg with report,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93041,Rhythm ecg tracing,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93042,Rhythm ecg report,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93050,Art pressure waveform analys,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93224,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93225,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93226,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93227,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93228,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93229,Remote 30 day ecg tech supp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93241,Ext ecg>48hr<7d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93242,Ext ecg>48hr<7d recording,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93243,Ext ecg>48hr<7d scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93244,Ext ecg>48hr<7d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93245,Ext ecg>7d<15d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93246,Ext ecg>7d<15d recording,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93247,Ext ecg>7d<15d scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93248,Ext ecg>7d<15d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93260,Prgrmg dev eval impltbl sys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93261,Interrogate subq defib,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93264,Rem mntr wrls p-art prs snr,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93268,Ecg record/review,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93270,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93271,Ecg/monitoring and analysis,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93272,Ecg/review interpret only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93278,Ecg/signal-averaged,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93279,Prgrmg dev eval pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93280,Pm device progr eval dual,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93281,Pm device progr eval multi,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93282,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93283,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93284,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93285,Prgrmg dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93286,Peri-px eval pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93287,Peri-px device eval & prgr,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93288,Interrog evl pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93289,Interrog device eval heart,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93290,Interrog dev eval icpms ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93291,Interrog dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93292,Wcd device interrogate,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93293,Pm phone r-strip device eval,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93294,Rem interrog evl pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93295,Dev interrog remote 1/2/mlt,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93296,Rem interrog evl pm/ids,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93297,Rem interrog dev eval icpms,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93298,Rem interrog dev eval scrms,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93299,Interrog eval icpms/scrms,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93303,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93304,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93306,Tte w/doppler complete,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93307,Tte w/o doppler complete,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93308,Tte f-up or lmtd,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93312,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93313,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93314,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93315,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93316,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93317,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93318,Echo transesophageal intraop,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93320,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93321,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93325,Doppler color flow add-on,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93350,Stress tte only,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93351,Stress tte complete,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93352,Admin ecg contrast agent,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93355,Echo transesophageal (tee),Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93356,Myocrd strain img spckl trck,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93451,Right heart cath,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93452,Left hrt cath w/ventrclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93453,R&l hrt cath w/ventriclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93454,Coronary artery angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93455,Coronary art/grft angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93456,R hrt coronary artery angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93457,R hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93458,L hrt artery/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93459,L hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93460,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93461,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93462,L hrt cath trnsptl puncture,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93464,Exercise w/hemodynamic meas,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93505,Biopsy of heart lining,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93530,Rt heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93531,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93532,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93533,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93600,Bundle of his recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93602,Intra-atrial recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93603,Right ventricular recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93609,Map tachycardia add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93610,Intra-atrial pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93612,Intraventricular pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93613,Electrophys map 3d add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93615,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93616,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93618,Heart rhythm pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93619,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93620,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93621,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93622,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93623,Stimulation pacing heart,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93624,Electrophysiologic study,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93631,Heart pacing mapping,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93640,Evaluation heart device,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93641,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93642,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93644,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93650,Ablate heart dysrhythm focus,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93653,Ep & ablate supravent arrhyt,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93654,Ep & ablate ventric tachy,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93655,Ablate arrhythmia add on,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93656,Tx atrial fib pulm vein isol,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93657,Tx l/r atrial fib addl,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93660,Tilt table evaluation,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93662,Intracardiac ecg (ice),Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Meridian Medicaid,CPT,93668,Peripheral vascular rehab,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93701,Bioimpedance cv analysis,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93702,Bis xtracell fluid analysis,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93724,Analyze pacemaker system,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93745,Set-up cardiovert-defibrill,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93750,Interrogation vad in person,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93770,Measure venous pressure,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93784,Ambl bp mntr w/software,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93786,Ambl bp mntr w/sw rec only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93788,Ambl bp mntr w/sw a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93790,Ambl bp mntr w/sw i&r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93792,Pt/caregiver traing home inr,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93793,Anticoag mgmt pt warfarin,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93797,Cardiac rehab,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93798,Cardiac rehab/monitor,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93799,Cardiovascular procedure,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93880,Extracranial bilat study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93882,Extracranial uni/ltd study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93886,Intracranial complete study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93888,Intracranial limited study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93890,Tcd vasoreactivity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93892,Tcd emboli detect w/o inj,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93893,Tcd emboli detect w/inj,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93895,Carotid intima atheroma eval,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93922,Upr/l xtremity art 2 levels,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93923,Upr/lxtr art stdy 3+ lvls,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93924,Lwr xtr vasc stdy bilat,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93925,Lower extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93926,Lower extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93930,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93931,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93965,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93970,Extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93971,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93975,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93976,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93978,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93979,Vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93980,Penile vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93981,Penile vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93982,Aneurysm pressure sens study,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93985,Dup-scan hemo compl bi std,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93986,Dup-scan hemo compl uni std,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93990,Doppler flow testing,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,93998,Noninvas vasc dx study proc,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94002,Vent mgmt inpat init day,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94003,Vent mgmt inpat subq day,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94004,Vent mgmt nf per day,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94005,Home vent mgmt supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94010,Breathing capacity test,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94011,Spirometry up to 2 yrs old,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94012,Spirmtry w/brnchdil inf-2 yr,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94013,Meas lung vol thru 2 yrs,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94014,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94015,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94016,Review patient spirometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94060,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94070,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94150,Vital capacity test,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94200,Lung function test (mbc/mvv),Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94250,Expired gas collection,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94375,Respiratory flow volume loop,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94400,Co2 breathing response curve,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94450,Hypoxia response curve,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94452,Hast w/report,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94453,Hast w/oxygen titrate,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94610,Surfactant admin thru tube,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94617,Exercise tst brncspsm w/ecg,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94618,Pulmonary stress testing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94619,Exercise tst brncspsm wo ecg,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94620,Pulmonary stress test/simple,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94621,Cardiopulm exercise testing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94640,Airway inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94642,Aerosol inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94644,Cbt 1st hour,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94645,Cbt each addl hour,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94660,Pos airway pressure cpap,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94662,Neg press ventilation cnp,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94664,Evaluate pt use of inhaler,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94667,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94668,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94669,Mechanical chest wall oscill,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94680,Exhaled air analysis o2,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94681,Exhaled air analysis o2/co2,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94690,Exhaled air analysis,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94726,Pulm funct tst plethysmograp,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94727,Pulm function test by gas,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94728,Airwy resist by oscillometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94729,Co/membane diffuse capacity,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94750,Pulmonary compliance study,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94762,Measure blood oxygen level,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94770,Exhaled carbon dioxide test,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94772,Breath recording infant,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94774,Ped home apnea rec compl,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94775,Ped home apnea rec hk-up,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94776,Ped home apnea rec downld,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94777,Ped home apnea rec report,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94780,Cars/bd tst inft-12mo 60 min,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94781,Cars/bd tst inft-12mo +30min,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,94799,Pulmonary service/procedure,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95004,Percut allergy skin tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95012,Exhaled nitric oxide meas,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95017,Perq & icut allg test venoms,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95018,Perq&ic allg test drugs/biol,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95024,Icut allergy test drug/bug,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95027,Icut allergy titrate-airborn,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95028,Icut allergy test-delayed,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95044,Allergy patch tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95052,Photo patch test,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95056,Photosensitivity tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95060,Eye allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95065,Nose allergy test,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95070,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95071,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95076,Ingest challenge ini 120 min,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95079,Ingest challenge addl 60 min,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95115,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95117,Immunotherapy injections,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95120,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95125,Immunotherapy 2/> injections,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95130,Immntx 1 sting insect,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95131,Immntx 2 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95132,Immntx 3 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95133,Immntx 4 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95134,Immntx 5 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95144,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95145,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95146,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95147,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95148,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95149,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95165,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95170,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95180,Rapid desensitization,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95199,Allergy immunology services,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95249,Cont gluc mntr pt prov eqp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95250,Cont gluc mntr phys/qhp eqp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95251,Cont gluc mntr analysis i&r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95700,Eeg cont rec w/vid eeg tech,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95705,Eeg w/o vid 2-12 hr unmntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95706,Eeg wo vid 2-12hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95707,Eeg w/o vid 2-12hr cont mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95708,Eeg wo vid ea 12-26hr unmntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95709,Eeg w/o vid ea 12-26hr intmt,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95710,Eeg w/o vid ea 12-26hr cont,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95711,Veeg 2-12 hr unmonitored,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95712,Veeg 2-12 hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95713,Veeg 2-12 hr cont mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95714,Veeg ea 12-26 hr unmntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95715,Veeg ea 12-26hr intmt mntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95716,Veeg ea 12-26hr cont mntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95717,Eeg phys/qhp 2-12 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95718,Eeg phys/qhp 2-12 hr w/veeg,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95719,Eeg phys/qhp ea incr w/o vid,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95720,Eeg phy/qhp ea incr w/veeg,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95721,Eeg phy/qhp>36<60 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95722,Eeg phy/qhp>36<60 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95723,Eeg phy/qhp>60<84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95724,Eeg phy/qhp>60<84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95725,Eeg phy/qhp>84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95726,Eeg phy/qhp>84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95782,Polysom <6 yrs 4/> paramtrs,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95783,Polysom <6 yrs cpap/bilvl,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95803,Actigraphy testing,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95805,Multiple sleep latency test,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95807,Sleep study attended,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95808,Polysom any age 1-3> param,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95810,Polysom 6/> yrs 4/> param,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95811,Polysom 6/>yrs cpap 4/> parm,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95812,Eeg 41-60 minutes,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95813,Eeg extnd mntr 61-119 min,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95816,Eeg awake and drowsy,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95819,Eeg awake and asleep,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95822,Eeg coma or sleep only,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95824,Eeg cerebral death only,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95827,Eeg all night recording,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95829,Surgery electrocorticogram,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95836,Ecog impltd brn npgt <30 d,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95857,Cholinesterase challenge,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95860,Muscle test one limb,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95861,Muscle test 2 limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95863,Muscle test 3 limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95864,Muscle test 4 limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95865,Muscle test larynx,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95866,Muscle test hemidiaphragm,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95867,Muscle test cran nerv unilat,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95868,Muscle test cran nerve bilat,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95869,Muscle test thor paraspinal,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95870,Muscle test nonparaspinal,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95872,Muscle test one fiber,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95873,Guide nerv destr elec stim,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95874,Guide nerv destr needle emg,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95875,Limb exercise test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95885,Musc tst done w/nerv tst lim,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95886,Musc test done w/n test comp,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95887,Musc tst done w/n tst nonext,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95905,Motor &/ sens nrve cndj test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95907,Nvr cndj tst 1-2 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95908,Nrv cndj tst 3-4 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95909,Nrv cndj tst 5-6 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95910,Nrv cndj test 7-8 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95911,Nrv cndj test 9-10 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95912,Nrv cndj test 11-12 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95913,Nrv cndj test 13/> studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95921,Autonomic nrv parasym inervj,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95922,Autonomic nrv adrenrg inervj,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95923,Autonomic nrv syst funj test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95924,Ans parasymp & symp w/tilt,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95925,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95926,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95927,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95928,C motor evoked uppr limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95929,C motor evoked lwr limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95930,Visual ep test cns w/i&r,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95933,Blink reflex test,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95937,Neuromuscular junction test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95938,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95939,C motor evoked upr&lwr limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95943,Parasymp&symp hrt rate test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95950,Ambulatory eeg monitoring,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95951,Eeg monitoring/videorecord,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95953,Eeg monitoring/computer,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95954,Eeg monitoring/giving drugs,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95955,Eeg during surgery,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95956,Eeg monitor technol attended,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95957,Eeg digital analysis,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95958,Eeg monitoring/function test,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95965,Meg spontaneous,Diagnostic Radiology,Per Unit,$221.34 ,OP,$221.34 ,$221.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95966,Meg evoked single,Diagnostic Radiology,Per Unit,$221.34 ,OP,$221.34 ,$221.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95967,Meg evoked each addl,Diagnostic Radiology,Per Unit,$221.34 ,OP,$221.34 ,$221.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95970,Alys npgt w/o prgrmg,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95971,Alys smpl sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95972,Alys cplx sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95973,Analyze neurostim complex,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95974,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95975,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95976,Alys smpl cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95977,Alys cplx cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95978,Analyze neurostim brain/1h,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95979,Analyz neurostim brain addon,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95980,Io anal gast n-stim init,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95981,Io anal gast n-stim subsq,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95982,Io ga n-stim subsq w/reprog,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95983,Alys brn npgt prgrmg 15 min,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95984,Alys brn npgt prgrmg addl 15,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,95999,Neurological procedure,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96000,Motion analysis video/3d,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96001,Motion test w/ft press meas,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96002,Dynamic surface emg,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96003,Dynamic fine wire emg,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96020,Functional brain mapping,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96101,Psycho testing by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96102,Psycho testing by technician,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96103,Psycho testing admin by comp,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96105,Assessment of aphasia,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96110,Developmental screen w/score,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96111,Developmental test extend,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96112,Devel tst phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96113,Devel tst phys/qhp ea addl,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96116,Nubhvl xm phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96118,Neuropsych tst by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96119,Neuropsych testing by tec,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96120,Neuropsych tst admin w/comp,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96121,Nubhvl xm phy/qhp ea addl hr,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96125,Cognitive test by hc pro,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96127,Brief emotional/behav assmt,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96130,Psycl tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96131,Psycl tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96132,Nrpsyc tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96133,Nrpsyc tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96137,Psycl/nrpsyc tst phy/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96138,Psycl/nrpsyc tech 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96139,Psycl/nrpsyc tst tech ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96146,Psycl/nrpsyc tst auto result,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96150,Assess hlth/behave init,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96151,Assess hlth/behave subseq,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96153,Intervene hlth/behave group,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96154,Interv hlth/behav fam w/pt,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96155,Interv hlth/behav fam no pt,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96156,Hlth bhv assmt/reassessment,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96160,Pt-focused hlth risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96161,Caregiver health risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96360,Hydration iv infusion init,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96361,Hydrate iv infusion add-on,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96365,Ther/proph/diag iv inf init,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96366,Ther/proph/diag iv inf addon,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96367,Tx/proph/dg addl seq iv inf,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96368,Ther/diag concurrent inf,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96369,Sc ther infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96370,Sc ther infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96371,Sc ther infusion reset pump,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96413,Chemo iv infusion 1 hr,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96415,Chemo iv infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96416,Chemo prolong infuse w/pump,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96417,Chemo iv infus each addl seq,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96422,Chemo ia infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96423,Chemo ia infuse each addl hr,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96425,Chemotherapy infusion method,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96446,Chemotx admn prtl cavity,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96450,Chemotherapy into cns,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96549,Chemotherapy unspecified,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96567,Pdt dstr prmlg les skn,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96570,Photodynmc tx 30 min add-on,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96571,Photodynamic tx addl 15 min,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96573,Pdt dstr prmlg les phys/qhp,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96574,Dbrdmt prmlg les w/pdt,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96900,Ultraviolet light therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96902,Trichogram,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96913,Photochemotherapy uv-a or b,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96920,Laser tx skin < 250 sq cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96921,Laser tx skin 250-500 sq cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96922,Laser tx skin >500 sq cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96931,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96932,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96933,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96934,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96935,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96936,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,96999,Dermatological procedure,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97001,Pt evaluation,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97002,Pt re-evaluation,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97003,Ot evaluation,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97004,Ot re-evaluation,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97010,Hot or cold packs therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97012,Mechanical traction therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97014,Electric stimulation therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97016,Vasopneumatic device therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97018,Paraffin bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97022,Whirlpool therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97024,Diathermy eg microwave,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97026,Infrared therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97028,Ultraviolet therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97032,Electrical stimulation,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97033,Electric current therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97034,Contrast bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97035,Ultrasound therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97039,Physical therapy treatment,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97116,Gait training therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97124,Massage therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97139,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97161,Pt eval low complex 20 min,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97162,Pt eval mod complex 30 min,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97163,Pt eval high complex 45 min,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97164,Pt re-eval est plan care,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97165,Ot eval low complex 30 min,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97166,Ot eval mod complex 45 min,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97167,Ot eval high complex 60 min,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97168,Ot re-eval est plan care,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97535,Self care mngment training,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97545,Work hardening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97546,Work hardening add-on,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97755,Assistive technology assess,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97762,C/o for orthotic/prosth use,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97799,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97802,Medical nutrition indiv in,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97803,Med nutrition indiv subseq,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97804,Medical nutrition group,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97810,Acupunct w/o stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97811,Acupunct w/o stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97813,Acupunct w/stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,97814,Acupunct w/stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98925,Osteopath manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98926,Osteopath manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98927,Osteopath manj 5-6 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98928,Osteopath manj 7-8 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98929,Osteopath manj 9-10 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98940,Chiropract manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98941,Chiropract manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98942,Chiropractic manj 5 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98943,Chiropract manj xtrspinl 1/>,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98960,Self-mgmt educ & train 1 pt,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98961,Self-mgmt educ/train 2-4 pt,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,98962,Self-mgmt educ/train 5-8 pt,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99050,Medical services after hrs,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99051,Med serv eve/wkend/holiday,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99053,Med serv 10pm-8am 24 hr fac,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99058,Office emergency care,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99060,Out of office emerg med serv,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99078,Group health education,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99091,Collj & interpj data ea 30 d,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99100,Special anesthesia service,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99116,Anesthesia with hypothermia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99135,Special anesthesia procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99140,Emergency anesthesia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99143,Mod sedat phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99144,Mod sedat phys/qhp 5yrs/>,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99145,Mod sedat phys/qhp ea 15 min,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99148,Mod sed diff phys/qhp<5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99149,Mod sed diff phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99150,Mod sed diff phys/qhp add on,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99151,Mod sed same phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99152,Mod sed same phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99153,Mod sed same phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99155,Mod sed oth phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99156,Mod sed oth phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99157,Mod sed other phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99172,Ocular function screen,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99173,Visual acuity screen,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99174,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99175,Induction of vomiting,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99177,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99188,App topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99238,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99239,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99363,Anticoagulant mgmt initial,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99364,Anticoagulant mgmt subseq,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99366,Team conf w/pat by hc prof,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99367,Team conf w/o pat by phys,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99368,Team conf w/o pat by hc pro,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99374,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99375,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99377,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99378,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99379,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99380,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99406,Behav chng smoking 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99407,Behav chng smoking > 10 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99408,Audit/dast 15-30 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99409,Audit/dast over 30 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99439,Chrnc care mgmt svc ea addl,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99453,Rem mntr physiol param setup,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99454,Rem mntr physiol param dev,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99457,Rem physiol mntr 1st 20 min,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99458,Rem physiol mntr ea addl 20,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99465,Nb resuscitation,General Medicine,Per Unit,$385.17 ,OP,$385.17 ,$385.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99473,Self-meas bp pt educaj/train,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99474,Self-meas bp 2 readg bid 30d,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99483,Assmt & care pln pt cog imp,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99484,Care mgmt svc bhvl hlth cond,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99487,Cplx chrnc care 1st 60 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99489,Cplx chrnc care ea addl 30,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99490,Chrnc care mgmt svc 1st 20,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99491,Chrnc care mgmt svc 30 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99492,1st psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99493,Sbsq psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99494,1st/sbsq psyc collab care,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99495,Trans care mgmt 14 day disch,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99496,Trans care mgmt 7 day disch,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99497,Advncd care plan 30 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99498,Advncd care plan addl 30 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99503,Home visit resp therapy,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,99504,Home visit mech ventilator,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0001M,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0002M,Liver dis 10 assays w/ash,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0002U,Onc clrct 3 ur metab alg plp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0003A,Fee covid-19 vac 1 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0003M,Liver dis 10 assays w/nash,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0003U,Onc ovar 5 prtn ser alg scor,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0004A,Fee covid-19 vac 1 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0004M,Scoliosis dna alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0004U,Nfct ds dna 27 resist genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0005U,Onco prst8 3 gene ur alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0006M,Onc hep gene risk classifier,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0006U,Detc ia meds 120+ analytes,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0007M,Onc gastro 51 gene nomogram,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0008M,Onc breast risk score,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0008U,Hpylori detcj abx rstnc dna,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0009M,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0010M,Onc prostate prob score,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0010U,Nfct ds strn typ whl gen seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0012U,Germln do gene reargmt detcj,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0013A,Fee covid-19 vac 2 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0013M,Onc mrna 5 gen recr urthl ca,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0013U,Onc sld org neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0014A,Fee covid-19 vac 2 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0014M,Liver ds alys 3 bmrk srm alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0014U,Hem hmtlmf neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0015M,Adrnl cortcl tum bchm asy 25,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0015U,Rx metab advrs rx rxn dna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0016M,Onc bladder mrna 209 gen alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0017M,Onc dlbcl mrna 20 genes alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0018U,Onc thyr 10 microrna seq alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0019T,Extracorp shock wv tx ms nos,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0019U,Onc rna tiss predict alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0020U,Rx test prsmv ur w/def conf,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0021A,Fee covid-19 vac 3 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0021U,Onc prst8 detcj 8 autoantb,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0022A,Fee covid-19 vac 3 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0022U,Trgt gen seq dna&rna 23 gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0023A,Fee covid-19 vac 3 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0023U,Onc aml dna detcj/nondetcj,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0024A,Fee covid-19 vac 3 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0024U,Glyca nuc mr spectrsc quan,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0025U,Tenofovir liq chrom ur quan,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0026U,Onc thyr dna&mrna 112 genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0027U,Jak2 gene trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0028U,Cyp2d6 gene cpy nmr cmn vrnt,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0029U,Rx metab advrs trgt seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0030U,Rx metab warf trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0031A,Fee covid-19 vac 4 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0031U,Cyp1a2 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0032A,Fee covid-19 vac 4 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0032U,Comt gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0033A,Fee covid-19 vac 4 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0033U,Htr2a htr2c genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0034A,Fee covid-19 vac 4 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0034U,Tpmt nudt15 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0035U,Neuro csf prion prtn qual,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0036U,Xome tum & nml spec seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0037U,Trgt gen seq dna 324 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0038U,Vitamin d srm microsamp quan,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0039U,Dna antb 2strand hi avidity,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0040U,Bcr/abl1 gene major bp quan,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0041A,Fee covid-19 vac 5 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0041U,B brgdrferi antb 5 prtn igm,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0042A,Fee covid-19 vac 5 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0042T,Ct perfusion w/contrast cbf,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0042U,B brgdrferi antb 12 prtn igg,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0043A,Fee covid-19 vac 5 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0043U,Tbrf b grp antb 4 prtn igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0044A,Fee covid-19 vac 5 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0044U,Tbrf b grp antb 4 prtn igg,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0045U,Onc brst dux carc is 12 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0046U,Flt3 gene itd variants quan,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0047U,Onc prst8 mrna 17 gene alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0048U,Onc sld org neo dna 468 gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0049U,Npm1 gene analysis quan,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0050U,Trgt gen seq dna 194 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0051A,Fee covid-19 vac 6 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0052A,Fee covid-19 vac 6 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0052U,Lpoprtn bld w/5 maj classes,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0053A,Fee covid-19 vac 6 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0053U,Onc prst8 ca fish alys 4 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0054A,Fee covid-19 vac 6 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0054U,Rx mntr 14+ drugs & sbsts,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0055U,Card hrt trnspl 96 dna seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0056U,Hem aml dna gene reargmt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0057U,Onc sld org neo mrna 51 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0058T,Cryopreservation ovary tiss,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0058U,Onc merkel cll carc srm quan,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0059U,Onc merkel cll carc srm +/-,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0060U,Twn zyg gen seq alys chrms2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0061A,Fee covid-19 vac 7 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0062A,Fee covid-19 vac 7 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0063A,Fee covid-19 vac 7 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0063U,Neuro autism 32 amines alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0064A,Fee covid-19 vac 7 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0064U,Antb tp total&rpr ia qual,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0065U,Syfls tst nontreponemal antb,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0066U,Pamg-1 ia cervico-vag fluid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0069U,Onc clrct microrna mir-31-3p,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0071A,Fee covid-19 vac 8 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0071U,Cyp2d6 full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0072A,Fee covid-19 vac 8 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0073A,Fee covid-19 vac 8 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0074A,Fee covid-19 vac 8 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0074U,Cyp2d6 nonduplicated gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0075T,Perq stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0075U,Cyp2d6 5' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0076T,S&i stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0076U,Cyp2d6 3' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0077U,Ig paraprotein qual bld/ur,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0078U,Pain mgt opi use gnotyp pnl,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0079U,Cmprtv dna alys mlt snps,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0080U,Onc lng 5 clin rsk factr alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0081A,Fee covid-19 vac 9 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0081U,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0082A,Fee covid-19 vac 9 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0083A,Fee covid-19 vac 9 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0083U,Onc rspse chemo cntrst tomog,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0084A,Fee covid-19 vac 9 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0084U,Rbc dna gnotyp 10 bld groups,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0085T,Breath test heart reject,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0085U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0086U,Nfct ds bact&fng org id 6+,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0088U,Trnsplj kdn algrft rej 1494,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0089U,Onc mlnma prame & linc00518,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0090U,Onc cutan mlnma mrna 23 gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0091A,Fee covid-19 vac 10 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0091U,Onc clrct scr whl bld alg,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0092A,Fee covid-19 vac 10 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0093A,Fee covid-19 vac 10 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0093U,Rx mntr 65 com drugs urine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0094A,Fee covid-19 vac 10 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0094U,Genome rapid sequence alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0095U,Inflm ee elisa alys alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0096U,Hpv hi risk types male urine,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0099T,Implant corneal ring,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0100T,Prosth retina receive&gen,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0101A,Fee covid-19 vac 11 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0101T,Extracorp shockwv tx hi enrg,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0101U,Hered colon ca do 15 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0102A,Fee covid-19 vac 11 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0102U,Hered brst ca rltd do 17 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0103A,Fee covid-19 vac 11 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0103T,Holotranscobalamin,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0103U,Hered ova ca pnl 24 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0104A,Fee covid-19 vac 11 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0104U,Hered pan ca pnl 32 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0105U,Neph ckd mult eclia tum nec,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0106T,Touch quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0107T,Vibrate quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0107U,C diff tox ag detcj ia stool,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0108T,Cool quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0109T,Heat quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0109U,Id aspergillus dna 4 species,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0110T,Nos quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0111T,Rbc membranes fatty acids,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0111U,Onc colon ca kras&nras alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0112U,Iadi 16s&18s rrna genes,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0114U,Gi barretts esoph vim&ccna1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0115U,Respir iadna 18 viral&2 bact,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0116U,Rx mntr nzm ia 35+oral flu,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0117U,Pain mgmt 11 endogenous anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0118U,Trnsplj don-drv cll-fr dna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0119U,Crd ceramides liq chrom plsm,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0120U,Onc b cll lymphm mrna 58 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0121U,Sc dis vcam-1 whole blood,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0122U,Sc dis p-selectin whl blood,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0123T,Scleral fistulization,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0123U,Mchnl fragility rbc prflg,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0124U,Ftl cgen abnor 3 analytes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0125U,Ftl cgen abnor prnt comp 5,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0126T,Chd risk imt study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0126U,Ftl cgen abnor prnt comp 5 y,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0127U,Ob pe 3 analytes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0128U,Ob pe 3 analytes y chrmsm,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0129U,Hered brst ca rltd do panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0130U,Hered colon ca do mrna pnl,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0131U,Hered brst ca rltd do pnl 13,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0132U,Hered ova ca rltd do pnl 17,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0133U,Hered prst8 ca rltd do 11,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0134U,Hered pan ca mrna pnl 18 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0136U,Atm mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0137U,Palb2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0138U,Brca1 brca2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0139U,Neuro austm meas 6 c metablt,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0140U,Nfct ds fungi dna 15 trgt,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0141U,Nfct ds bact&fng gram pos,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0142U,Nfct ds bact&fng gram neg,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0145U,Drug assay 65+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0146U,Drug assay 80+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0147U,Drug assay 85+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0148U,Drug assay 100+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0149U,Drug assay 60+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0151U,Nfct bct/vir resp nfctj 33,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0152U,Nfct ds dna untrgt ngnrj seq,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0153U,Onc breast mrna 101 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0154U,Onc urthl ca rna fgfr3 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0155U,Onc brst ca dna pik3ca gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0156U,Copy number sequence alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0157U,Apc mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0158U,Mlh1 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0159U,Msh2 mrna seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0160U,Msh6 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0161U,Pms2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0162U,Hered colon ca trgt mrna pnl,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0163U,Onc clrct scr 3 prtn alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0164U,Gi ibs ia anti-cdtb&vinculin,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0165U,Peanut allg asmt epi,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0166U,Liver ds 10 biochem asy srm,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0167U,Chornc gonadotropin hcg ia,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0168U,Ftl aneuploidy dna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0169U,Nudt15&tpmt gene com vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0170U,Neuro asd rna next gen seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0171U,Trgt gen seq alys pnl dna 23,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0172T,Lumbar spine process addl,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0172U,Onc sld tum alys brca1 brca2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0173U,Psyc gen alys panel 14 genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0174U,Onc solid tumor 30 prtn trgt,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0175U,Psyc gen alys panel 15 genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0176U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0177U,Onc brst ca dna pik3ca 11,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0178T,64 lead ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0178U,Peanut allg asmt epi clin rx,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0179T,64 lead ecg w/tracing,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0179U,Onc nonsm cll lng ca alys 23,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0180U,Abo gnotyp abo 7 exons,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0181U,Co gnotyp aqp1 exon 1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0182T,Hdr elect brachytherapy,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0182U,Crom gnotyp cd55 exons 1-10,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0183U,Di gnotyp slc4a1 exon 19,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0184T,Exc rectal tumor endoscopic,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0184U,Do gnotyp art4 exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0185U,Fut1 gnotyp fut1 exon 4,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0186U,Fut2 gnotyp fut2 exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0188U,Ge gnotyp gypc exons 1-4,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0191T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0191U,In gnotyp cd44 exons 2 3 6,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0192U,Jk gnotyp slc14a1 exon 9,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0194U,Kel gnotyp kel exon 8,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0195U,Klf1 targeted sequencing,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0196U,Lu gnotyp bcam exon 3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0197U,Lw gnotyp icam4 exon 1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0198T,Ocular blood flow measure,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0199U,Sc gnotyp ermap exons 4 12,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0200U,Xk gnotyp xk exons 1-3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0201U,Yt gnotyp ache exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0203U,Ai ibd mrna xprsn prfl 17,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0204U,Onc thyr mrna xprsn alys 593,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0205T,Inirs each vessel add-on,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0205U,Oph amd alys 3 gene variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0206T,Cptr dbs alys car elec dta,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0206U,Neuro alzheimer cell aggregj,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0207T,Clear eyelid gland w/heat,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0207U,Neuro alzheimer quan imaging,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0208U,Onc mtc mrna xprsn alys 108,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0209U,Cytog const alys interrog,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0210U,Syphilis tst antb ia quan,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0211U,Onc pan-tum dna&rna gnrj seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0212T,Compre audiometry evaluation,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0212U,Rare ds gen dna alys proband,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0213U,Rare ds gen dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0214U,Rare ds xom dna alys proband,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0215T,Njx paravert w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0215U,Rare ds xom dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0216U,Neuro inh ataxia dna 12 com,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0217U,Neuro inh ataxia dna 51 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0218U,Neuro musc dys dmd seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0219U,Nfct agt hiv gnrj seq alys,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0220U,Onc brst ca ai assmt 12 feat,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0221U,Abo gnotyp next gnrj seq abo,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0222U,Rhd&rhce gntyp next gnrj seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0223T,Acoustic ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0224T,Acoustic ecg 1+ analysis,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0224U,Antibody sars-cov-2 titer(s),Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0225T,Acoustic ecg analy & reprog,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0226U,Svnt sarscov2 elisa plsm srm,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0227U,Rx asy prsmv30+rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0228T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0228U,Onc prst8 ma molec prfl alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0229T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0229U,Bcat1 promoter mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0230U,Ar full sequence analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0231U,Cacna1a full gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0232T,Njx platelet plasma,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0232U,Cstb full gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0233T,Skin glycation spectroscopy,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0233U,Fxn gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0234U,Mecp2 full gene analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0235T,Trluml perip athrc visceral,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0235U,Pten full gene analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0236T,Trluml perip athrc abd aorta,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0236U,Smn1&smn2 full gene analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0237T,Trluml perip athrc brchiocph,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0237U,Car ion chnlpthy gen seq pnl,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0238T,Trluml perip athrc iliac art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0238U,Onc lnch syn gen dna seq aly,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0239U,Trgt gen seq alys pnl 311+,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0240T,Esoph motility 3d topography,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0241T,Esoph motility w/stim/perf,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0243T,Intm msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0244T,Cont msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0249T,Ligation hemorrhoid w/us,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0253T,Insert aqueous drain device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0255T,Evasc rpr iliac art bifr s&i,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0263T,Im b1 mrw cel ther cmpl,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0264T,Im b1 mrw cel ther xcl hrvst,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0265T,Im b1 mrw cel ther hrvst onl,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0266T,Implt/rpl crtd sns dev total,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0267T,Implt/rpl crtd sns dev lead,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0268T,Implt/rpl crtd sns dev gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0269T,Rev/remvl crtd sns dev total,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0270T,Rev/remvl crtd sns dev lead,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0271T,Rev/remvl crtd sns dev gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0272T,Interrogate crtd sns dev,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0273T,Interrogate crtd sns w/pgrmg,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0278T,Tempr,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0282T,Periph field stimul trial,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0283T,Periph field stimul perm,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0284T,Periph field stimul revise,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0285T,Periph field stimul analys,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0286T,Near ifr spectrsc of wounds,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0288T,Anoscopy w/rf delivery,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0289T,Laser inc for pkp/lkp donor,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0290T,Laser inc for pkp/lkp recip,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0294T,Ins lt atrl mont pres lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0295T,Ext ecg complete,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0296T,Ext ecg recording,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0297T,Ext ecg scan w/report,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0298T,Ext ecg review and interp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0301T,Mw therapy for breast tumor,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0302T,Icar ischm mntrng sys compl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0303T,Icar ischm mntrng sys eltrd,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0304T,Icar ischm mntrng sys device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0305T,Icar ischm mntrng prgrm eval,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0306T,Icar ischm mntr interr eval,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0307T,Rmvl icar ischm mntrng dvce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0308T,Insj ocular telescope prosth,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0310T,Motor function mapping ntms,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0311T,Cal & alys cntrl artl press,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0312T,Laps impltj nstim vagus,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0313T,Laps rmvl nstim array vagus,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0314T,Laps rmvl vgl arry&pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0315T,Rmvl vagus nerve pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0316T,Replc vagus nerve pls gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0317T,Elec alys vagus nrv pls gen,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0329T,Mntr io press 24hrs/> uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0330T,Tear film img uni/bi w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0331T,Heart symp image plnr,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0332T,Heart symp image plnr spect,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0333T,Visual ep scr acuity auto,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0335T,Insj sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0337T,Endothel fxnassmnt non-invas,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0341T,Quant pupillometry w/ rprt,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0342T,Thxp apheresis w/hdl delip,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0346T,Ultrasound elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0348T,Rsa spine exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0349T,Rsa upper extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0350T,Rsa lower extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0352T,Oct brst/node i&r per spec,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0354T,Oct breast surg cavity i&r,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0355T,Gi tract capsule endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0356T,Insrt drug device for iop,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0357T,Cryopreservation oocyte(s),Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0358T,Bia whole body,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0362T,Bhv id suprt assmt ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0373T,Adapt bhv tx ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0376T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0377T,Anoscpy inj agent for incont,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0378T,Visual field assmnt rev/rprt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0379T,Vis field assmnt tech suppt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0380T,Comp animat ret imag series,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0381T,Ext h rate epi sz 14 days,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0382T,Ext h rate sz 14 day ri only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0383T,Ext h rate sz up to 30 days,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0384T,Ex h rate sz 30 day ri only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0385T,Ex h rate for sz ovr 30 day,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0386T,Ex h rate sz 30+ day ri only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0387T,Leadless c pm ins/rpl ventr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0388T,Leadless c pm remove ventr,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0389T,Prog eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0390T,Periproc eval inper ledls pm,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0391T,Intergt eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0392T,Lap es sph augment dev place,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0393T,Es sph augmnt device removal,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0394T,Hdr elctrnc skn surf brchytx,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0398T,Mrgfus strtctc les abltj,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0399T,Myocardial strain imaging,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0400T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0401T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0402T,Colgn cross-link crn med sep,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0403T,Diabetes prev standard curr,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0406T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0407T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0408T,Insj/rplc cardiac modulj sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0409T,Insj/rplc car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0412T,Rmvl cardiac modulj pls gen,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0414T,Rmvl & rpl car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0417T,Prgrmg eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0418T,Interro eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0419T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0420T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0421T,Waterjet prostate abltj cmpl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0422T,Tactile breast img uni/bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0423T,Assay secretory type ii pla2,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0424T,Insj/rplc nstim apnea compl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0425T,Insj/rplc nstim apnea sen ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0426T,Insj/rplc nstim apnea stm ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0427T,Insj/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0428T,Rmvl nstim apnea pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0429T,Rmvl nstim apnea sen ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0430T,Rmvl nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0431T,Rmvl/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0432T,Repos nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0433T,Repos nstim apnea sensing ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0434T,Interro eval npgs apnea,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0435T,Prgrmg eval npgs apnea 1 ses,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0436T,Prgrmg eval npgs apnea study,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0437T,Impltj synth rnfcmt abdl wal,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0438T,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0439T,Myocrd contrast prfuj echo,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0440T,Abltj perc uxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0441T,Abltj perc lxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0442T,Abltj perc plex/trncl nrv,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0443T,R-t spctrl alys prst8 tiss,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0446T,Insj impltbl glucose sensor,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0447T,Rmvl impltbl glucose sensor,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0448T,Remvl insj impltbl gluc sens,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0449T,Insj aqueous drain dev 1st,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0450T,Insj aqueous drain dev each,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0453T,Insj/rplcmt mech-elec ntrfce,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0457T,Remvl mech-elec skin ntrfce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0462T,Prgrmg eval aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0463T,Interrog aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0464T,Visual ep test for glaucoma,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0466T,Insj ch wal respir eltrd/ra,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0467T,Revj/rplmnt ch respir eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0468T,Rmvl ch wal respir eltrd/ra,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0469T,Rta polarize scan oc scr bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0470T,Oct skn img acquisj i&r 1st,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0471T,Oct skn img acquisj i&r addl,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0472T,Prgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0473T,Reprgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0474T,Insj aqueous drg dev io rsvr,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0475T,Rec ftl car sgl 3 ch i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0476T,Rec ftl car sgl elec tr data,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0477T,Rec ftl car sgl xrtj alys,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0478T,Rec ftl car 3 ch rev i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0481T,Njx autol wbc concentrate,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0482T,Absl quan myocrd bld flo pet,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0485T,Oct mid ear i&r unilateral,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0486T,Oct mid ear i&r bilateral,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0487T,Trvg biomchn mapg w/reprt,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0488T,Diabetes prev online/elec,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0489T,Regn cell tx scldr hands,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0490T,Regn cell tx scldr h mlt inj,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0497T,Xtrnl pt act ecg in-off conn,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0498T,Xtrnl pt act ecg r&i pr 30 d,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0499T,Cysto f/urtl strix/stenosis,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0500T,Hpv 5+ hi risk hpv types,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0501T,Cor ffr derived cor cta data,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0502T,Cor ffr data prep & transmis,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0503T,Cor ffr alys gnrj ffr mdl,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0504T,Cor ffr data review i&r,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0505T,Ev fempop artl revsc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0506T,Mac pgmt opt dns meas hfp,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0507T,Near ifr 2img mibmn glnd i&r,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0508T,Pls echo us b1 dns meas tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0509T,Pattern erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0510T,Rmvl sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0511T,Rmvl&rinsj sinus tarsi implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0514T,Intraop vis axis id pt fixj,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0515T,Insj wcs lv compl sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0517T,Insj wcs lv pg compnt,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0518T,Rmvl pg compnt wcs,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0519T,Rmvl & rplcmt pg compnt wcs,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0521T,Interrog dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0522T,Prgrmg dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0525T,Insj/rplcmt compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0527T,Insj/rplcmt iims implt mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0528T,Prgrmg dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0529T,Interrog dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0530T,Removal complete iims,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0532T,Removal iims implt mntr only,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0533T,Cont rec mvmt do 6-10 days,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0534T,Cont rec mvmt do setup&train,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0535T,Cont rec mvmt do reprt cnfig,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0536T,Cont rec mvmt do dl w/i&r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0541T,Myocardial imaging mcg,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0542T,Myocardial imaging mcg i&r,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0546T,Rf spectrsc ntraop mrgn asmt,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0547T,B1 matrl qual tst mcrind tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0548T,Tprnl balo cntnc dev bi,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0549T,Tprnl balo cntnc dev uni,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0550T,Tprnl balo cntnc dev rmvl ea,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0551T,Tprnl balo cntnc dev adjmt,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0552T,Low-level laser therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0553T,Perq tcat iliac anast implt,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0554T,B1 str & fx rsk analysis,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0556T,B1 str & fx rsk assessment,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0558T,Ct scan f/biomchn ct alys,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0563T,Evac meibomian glnd heat bi,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0564T,Onc chemo rx cytotox csc 14,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0566T,Autol cell implt adps njx,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0568T,Intro mix saline&air f/ssg,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0571T,Insj/rplcmt icds ss eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0575T,Prgrmg dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0576T,Interrog dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0577T,Ephys eval icds ss,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0578T,Rem interrog dev icds phys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0579T,Rem interrog dev icds tech,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0581T,Abltj mal brst tum perq crtx,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0582T,Trurl abltj mal prst8 tiss,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0583T,Tmpst auto tube dlvr sys,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0587T,Perq impltj/rplcmt isdns ptn,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0588T,Revision/removal isdns ptn,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0589T,Elec alys smpl prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0590T,Elec alys cplx prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0591T,Hlth&wb coaching indiv 1st,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0592T,Hlth&wb coaching indiv f-up,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0593T,Hlth&wb coaching group,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0596T,Temp fml iu vlv-pmp 1st insj,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0597T,Temp fml iu valve-pmp rplcmt,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0602T,Transdermal gfr measurements,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0603T,Transdermal gfr monitoring,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0604T,Rem oct rta dev setup&educaj,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0605T,Rem oct rta techl sprt min 8,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0607T,Rem mntr pulm flu mntr setup,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0608T,Rem mntr pulm flu mntr alys,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0609T,Mrs disc pain acquisj data,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0610T,Mrs disc pain transmis data,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0611T,Mrs disc pain alg alys data,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0615T,Eye mvmt alys w/o calbrj i&r,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0616T,Insertion of iris prosthesis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0617T,Insj iris prosth w/rmvl&insj,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0618T,Insj iris prosth sec io lens,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0619T,Cysto w/prst8 commissurotomy,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0620T,Evasc ven artlz tibl/prnl vn,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0621T,Trabeculostomy interno laser,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0622T,Trabeculostomy int lsr w/scp,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0623T,Auto quantification c plaque,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0632T,Perq tcat us abltj nrv p-art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,0633T,Ct breast w/3d uni c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0634T,Ct breast w/3d uni c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0635T,Ct breast w/3d uni c-/c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0636T,Ct breast w/3d bi c-,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0637T,Ct breast w/3d bi c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0638T,Ct breast w/3d bi c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,0639T,Wrls skn snr anisotropy meas,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C1762,"Conn tiss, human(inc fascia)",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C1763,"Conn tiss, non-human",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C1849,"Skin substitute, synthetic",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C1878,Matrl for vocal cord,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C2615,"Sealant, pulmonary, liquid",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8900,"Mra w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8901,"Mra w/o cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8902,"Mra w/o fol w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8903,"Mri w/cont, breast, uni",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8904,"Mri w/o cont, breast, uni",Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8905,"Mri w/o fol w/cont, brst, un",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8906,"Mri w/cont, breast, bi",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8907,"Mri w/o cont, breast, bi",Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8908,"Mri w/o fol w/cont, breast,",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8909,"Mra w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8910,"Mra w/o cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8911,"Mra w/o fol w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8912,"Mra w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8913,"Mra w/o cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8914,"Mra w/o fol w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8918,"Mra w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8919,"Mra w/o cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8920,"Mra w/o fol w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8921,"Tte w or w/o fol w/cont, com",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8922,"Tte w or w/o fol w/cont, f/u",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8923,"2d tte w or w/o fol w/con,co",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8924,"2d tte w or w/o fol w/con,fu",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8925,"2d tee w or w/o fol w/con,in",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8926,"Tee w or w/o fol w/cont,cong",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8927,"Tee w or w/o fol w/cont, mon",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8928,"Tte w or w/o fol w/con,stres",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8929,"Tte w or wo fol wcon,doppler",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8930,"Tte w or w/o contr, cont ecg",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8931,"Mra, w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8932,"Mra, w/o dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8933,"Mra, w/o&w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8934,"Mra, w/dye, upper extremity",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8935,"Mra, w/o dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8936,"Mra, w/o&w/dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C8957,"Prolonged iv inf, req pump",General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9014,"Injection, cerliponase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9015,"C-1 esterase, haegarda",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9016,"Inj, triptorelin ext rel",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9024,"Inj, daunorubicin-cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9025,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9026,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9027,"Injection, pembrolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9028,Inj. inotuzumab ozogamicin,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9029,"Injection, guselkumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9030,Inj copanlisib,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9031,"Lutetium Lu 177 dotatate, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9032,Voretigene neparvovec-rzyl,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9033,"Inj, akynzeo",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9034,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9035,"Injection, Aristada Initio",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9036,"Injection, patisiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9037,"Injection, risperidone",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9038,Inj mogamulizumab-kpkc,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9040,"Injection, fremanezumab-vfrm",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9041,"Inj, coagulation factor xa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9042,"Inj., belrapzo 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9043,"Injection, levoleucovorin",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9044,"Injection, cemiplimab-rwlc",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9045,Moxetumomab pasudotox-tdfk,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9047,"Injection, caplacizumab-yhdp",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9048,Dexamethasone ophth insert,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9049,"Injection, tagraxofusp-erzs",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9050,"Injection, emapalumab-lzsg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9051,"Injection, omadacycline",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9052,"Injection, ravulizumab-cwv",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9053,"Inj, crizanlizumab-tmca",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9054,"Injection, lefamulin",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9055,"Inj, brexanolone",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9056,"Injection, givosiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9057,Inj cetirizine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9058,"Injection,pegfilgrastim-bmez",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9059,"Injection, meloxicam",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9061,"Injection, teprotumumab-trbw",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9062,Daratumumab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9063,"Injection, eptinezumab-jjmr",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9064,Mitomycin pyelocalyceal inst,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9065,Romidepsin non-lyophilized,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9066,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9069,Belantamab mafodontin-blmf,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9070,"Injection, tafasitamab-cxix",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9071,"Injection, viltolarsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9072,"Inj, imm glob asceniv",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9121,"Injection, argatroban",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9122,Mometasone furoate (sinuva),Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9132,"Kcentra, per i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9137,Adynovate Factor VIII recom,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9138,Nuwiq Factor VIII recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9139,"Idelvion, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9140,Afstyla factor viii recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9141,Factor viii pegylated-aucl,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9248,"Inj, clevidipine butyrate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9250,Artiss fibrin sealant,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9257,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9293,"Injection, glucarpidase",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9349,"Puraply, puraply antimic",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9352,"Neuragen nerve guide, per cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9353,"Neurawrap nerve protector,cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9354,"Veritas collagen matrix, cm2",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9355,"Neuromatrix nerve cuff, cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9356,"Tenoglide tendon prot, cm2",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9358,"Surgimend, fetal",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9359,"Implnt,bon void filler-putty",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9360,"Surgimend, neonatal",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9361,Neuromend nerve wrap,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9362,"Implnt,bon void filler-strip",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9363,Integra meshed bil wound mat,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9364,"Porcine implant, permacol",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9408,"Iodine i-131 iobenguane, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9442,"Injection, belinostat",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9443,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9444,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9445,"C-1 esterase, Ruconest",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9446,"Inj, tedizolid phosphate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9447,"Inj, phenylephrine ketorolac",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9448,Oral netupitant palonosetron,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9449,"Inj, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9450,Fluocinolone acetonide implt,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9451,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9452,"Inj, ceftolozane/tazobactam",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9453,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9454,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9455,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9456,"Inj, isavuconazonium sulfate",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9460,"Injection, cangrelor",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9465,"Injection, Durolane",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9466,"Injection, benralizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9467,Inj rituximab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9468,"Inj, factor ix, Rebinyn",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9469,Inj triamcinolone acetonide,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9470,Aripiprazole lauroxil im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9471,"Hymovis, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9472,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9473,"Injection, mepolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9474,"Inj, irinotecan liposome",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9475,"Injection, necitumumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9476,"Injection, daratumumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9477,"Injection, elotuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9478,"Injection, sebelipase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9480,"Injection, trabectedin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9481,"Injection, reslizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9482,Sotalol hydrochloride iv,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9483,"Injection, atezolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9484,"Injection, eteplirsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9485,"Injection, olaratumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9487,"Ustekinumab IV inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9488,Conivaptan hcl,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9489,"Injection, nusinersen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9490,"Injection, bezlotoxumab",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9491,"Injection, avelumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9492,"Injection, durvalumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9493,"Injection, edaravone",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9494,"Injection, ocrelizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9497,"Loxapine, inhalation powder",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9600,Perc drug-el cor stent sing,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9601,Perc drug-el cor stent bran,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9602,Perc d-e cor stent ather s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9603,Perc d-e cor stent ather br,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9604,Perc d-e cor revasc t cabg s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9605,Perc d-e cor revasc t cabg b,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9606,Perc d-e cor revasc w ami s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9607,Perc d-e cor revasc chro sin,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9608,Perc d-e cor revasc chro add,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9724,Eps stomach plic,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9726,Rxt breast appl place/remov,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9728,"Place device/marker, non pro",Therapeutic Radiology,Per Unit,$68.45 ,OP,$68.45 ,$68.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9734,"U/s trtmt, not leiomyomata",General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9737,Lap esoph augmentation,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9739,Cystoscopy prostatic imp 1-3,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9740,Cysto impl 4 or more,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9741,Impl pressure sensor w/angio,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9742,Laryngoscopy with injection,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9743,Bulking/spacer material impl,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9744,Abd us w/contrast,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9745,Nasal endo eustachian tube,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9747,"Ablation, hifu, prostate",Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9749,Repair nasal stenosis w/imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9750,Ins/rem-replace compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9762,Cardiac mri seg dys strain,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9763,Cardiac mri seg dys stress,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9765,Revasc intra lithotrip-stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9767,Revasc lithotrip-stent-ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9768,Endo us-guide hep porto grad,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,C9769,Cysto w/temp pros implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9770,"Vitrec/mech pars, subret inj",Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9771,Nsl/sins cryo post nasal tis,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9772,Revasc lithotrip tibi/perone,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9773,Revasc lithotr-stent tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9774,Revasc lithotr-ather tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9775,Revasc lith-sten-ath tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Meridian Medicaid,CPT,C9803,Hopd covid-19 spec collect,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0120,Periodic oral evaluation,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0140,Limit oral eval problm focus,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0145,"Oral evaluation, pt < 3yrs",Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0150,Comprehensve oral evaluation,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0160,Extensv oral eval prob focus,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0170,"Re-eval,est pt,problem focus",Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0171,Re-eval post-op visit,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0180,Comp periodontal evaluation,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0190,Screening of a patient,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0191,Assessment of a patient,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0210,Intraor complete film series,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0220,Intraoral periapical first,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0230,Intraoral periapical ea add,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0240,Intraoral occlusal film,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0250,Extraoral 2d project image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0251,Extraoral posterior image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0260,Extraoral ea additional film,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0270,Dental bitewing single image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0272,Dental bitewings two images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0273,Bitewings - three images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0274,Bitewings four images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0277,Vert bitewings 7 to 8 images,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0290,Skull/facial bone image,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0310,Dental saliography,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0320,Dental tmj arthrogram incl i,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0321,Other tmj images by report,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0322,Dental tomographic survey,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0330,Panoramic image,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0340,2d cephalometric image,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0350,Oral/facial photo images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0351,3d photographic image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0364,Cone beam ct capt & interp,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0365,Cone beam ct interprete man,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0366,Cone beam ct interprete max,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0367,Cone beam ct interp both jaw,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0368,Cone beam ct interprete tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0369,Max mri capture & interprete,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0370,Max ultrasound capt & interp,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0371,Sialoendoscopy capt & interp,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0380,Cone beam ct capture limited,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0381,Cone beam ct capt mandible,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0382,Cone beam ct capt maxilla,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0383,Cone beam ct both jaws,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0384,Cone beam ct capture tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0385,Max mri image capture,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0386,Max ultrasound image capture,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0391,Imterprete diagnostic image,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0393,Trtmnt simulation 3d image,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0394,Digital sub 2 or more images,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0395,Fusion 2 or more 3d images,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0411,Hba1c in office testing,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0412,Blood glucose level test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0414,Lab process microbial spec,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0415,Collection of microorganisms,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0416,Viral culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0418,Analysis of saliva sample,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0419,Assess of salivary flow,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0421,Gen tst suscept oral disease,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0422,Collect & prep genetic samp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0423,Genetic test spec analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0425,Caries susceptibility test,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0431,Diag tst detect mucos abnorm,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0460,Pulp vitality test,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0470,Diagnostic casts,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0472,"Gross exam, prep & report",Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0473,"Micro exam, prep & report",Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0474,Micro w exam of surg margins,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0475,Decalcification procedure,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0476,Spec stains for microorganis,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0477,Spec stains not for microorg,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0478,Immunohistochemical stains,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0479,Tissue in-situ hybridization,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0480,Cytopath smear prep & report,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0481,Electron microscopy,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0482,Direct immunofluorescence,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0483,Indirect immunofluorescence,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0484,Consult slides prep elsewher,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0485,Consult inc prep of slides,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0486,Access of transep cytol samp,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0502,Other oral pathology procedu,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0600,Non-ionizing diag proc,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0601,Caries risk assess low risk,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0602,Caries risk assess mod risk,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0603,Caries risk assess high risk,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0604,Antigen test pub hlth pathog,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0605,Antibody test pub hlth path,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0701,Pano radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0702,2d cephal radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0703,2d oral/facial photo image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0704,3d photo image capture only,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0705,Extra oral post radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0706,Intraoral occlus radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0707,Intraoral periap radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0708,Intraoral bite radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0709,Intraoral cmplt radio images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D0999,Unspecified diagnostic proce,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1110,Dental prophylaxis adult,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1120,Dental prophylaxis child,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1206,Topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1208,Topical app fluorid ex vrnsh,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1310,Nutri counsel-control caries,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1320,Tobacco counseling,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1321,Couns for high risk sub use,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1330,Oral hygiene instruction,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1351,Dental sealant per tooth,Dental,Per Unit,$24.50 ,OP,$24.50 ,$24.50 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1352,"Prev resin rest, perm tooth",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1353,Sealant repair per tooth,Dental,Per Unit,$24.50 ,OP,$24.50 ,$24.50 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1354,Int caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1355,Caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1510,Space maintainer fxd unilat,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1515,Fixed bilat space maintainer,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1516,"Fixed bilat space maint, max",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1517,"Fixed bilat space maint, man",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1520,Remove unilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1525,Remove bilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1526,"Remove bilat space main, max",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1527,"Remove bilat space main, man",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1550,Recement space maintainer,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1551,Recement space maint - max,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1552,Recement space maint - man,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1553,Recement unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1555,Remove fix space maintainer,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1556,Rem fixed unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1557,Remove fixed bilat maint max,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1558,Remove fixed bilat man,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1575,"Dist space maint, fixed unil",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D1999,Unspecified preventive proc,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2140,Amalgam one surface permanen,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2150,Amalgam two surfaces permane,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2160,Amalgam three surfaces perma,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2161,Amalgam 4 or > surfaces perm,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2330,Resin one surface-anterior,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2331,Resin two surfaces-anterior,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2332,Resin three surfaces-anterio,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2335,Resin 4/> surf or w incis an,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2390,Ant resin-based cmpst crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2391,Post 1 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2392,Post 2 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2393,Post 3 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2394,Post >=4srfc resinbase cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2410,Dental gold foil one surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2420,Dental gold foil two surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2430,Dental gold foil three surfa,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2510,Dental inlay metalic 1 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2520,Dental inlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2530,Dental inlay metl 3/more sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2542,Dental onlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2543,Dental onlay metallic 3 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2544,Dental onlay metl 4/more sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2610,Inlay porcelain/ceramic 1 su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2620,Inlay porcelain/ceramic 2 su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2630,Dental onlay porc 3/more sur,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2642,Dental onlay porcelin 2 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2643,Dental onlay porcelin 3 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2644,Dental onlay porc 4/more sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2650,Inlay composite/resin one su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2651,Inlay composite/resin two su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2652,Dental inlay resin 3/mre sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2662,Dental onlay resin 2 surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2663,Dental onlay resin 3 surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2664,Dental onlay resin 4/mre sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2710,Crown resin-based indirect,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2712,Crown 3/4 resin-based compos,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2720,Crown resin w/ high noble me,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2721,Crown resin w/ base metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2722,Crown resin w/ noble metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2740,Crown porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2750,Crown porcelain w/ h noble m,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2751,Crown porcelain fused base m,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2752,Crown porcelain w/ noble met,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2753,Crown porc fused to titanium,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2780,Crown 3/4 cast hi noble met,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2781,Crown 3/4 cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2782,Crown 3/4 cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2790,Crown full cast high noble m,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2791,Crown full cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2792,Crown full cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2794,Crown-titanium,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2799,Provisional crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2910,Recement inlay onlay or part,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2915,Recement cast or prefab post,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2920,Re-cement or re-bond crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2921,Reattach tooth fragment,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2928,Prefab porc/cer crown perm,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2929,Prefab porc/ceram crown pri,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2930,Prefab stnlss steel crwn pri,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2931,Prefab stnlss steel crown pe,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2932,Prefabricated resin crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2933,Prefab stainless steel crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2934,Prefab steel crown primary,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2941,Int therapeutic restoration,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2950,Core build-up incl any pins,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2951,Tooth pin retention,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2952,Post and core cast + crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2953,Each addtnl cast post,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2954,Prefab post/core + crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2955,Post removal,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2957,Each addtnl prefab post,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,D2960,Labial veneer resin direct,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2961,Labial veneer resin indirect,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2962,Labial veneer porc indirect,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2970,Temp crown (fractured tooth),Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2971,Add proc construct new crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2975,Coping,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2980,Crown repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2981,Inlay repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2982,Onlay repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2983,Veneer repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2990,Resin infiltration of lesion,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D2999,Dental unspec restorative pr,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3110,Pulp cap direct,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3120,Pulp cap indirect,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3220,Therapeutic pulpotomy,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3221,Gross pulpal debridement,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3222,Part pulp for apexogenesis,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3230,Pulpal therapy anterior prim,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3240,Pulpal therapy posterior pri,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3310,"End thxpy, anterior tooth",Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3320,"End thxpy, premolar tooth",Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3330,"End thxpy, molar tooth",Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3331,Non-surg tx root canal obs,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3332,Incomplete endodontic tx,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3333,Internal root repair,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3346,Retreat root canal anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3347,Retreat root canal premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3348,Retreat root canal molar,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3351,Apexification/recalc initial,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3352,Apexification/recalc interim,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3353,Apexification/recalc final,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3355,Pulpal regeneration initial,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3356,Pulpal regeneration interim,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3357,Pulpal regeneration complete,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3410,Apicoectomy - anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3421,Root surgery premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3425,Root surgery molar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3426,Root surgery ea add root,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3427,Periradicular surgery,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3428,Bone graft peri per tooth,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3429,Bone graft peri each addl,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3430,Retrograde filling,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3431,Biological materials,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3432,Guided tissue regeneration,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3450,Root amputation,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3460,Endodontic endosseous implan,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3470,Intentional replantation,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3471,Surg rep root res anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3472,Surg rep root res premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3473,Surg rep root res molar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3501,Surg exp root surf anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3502,Surg exp root surf premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3503,Surg exp root surf molar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3910,Isolation- tooth w rubb dam,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3920,Tooth splitting,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3950,Canal prep/fitting of dowel,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D3999,Endodontic procedure,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4210,Gingivectomy/plasty 4 or mor,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4211,Gingivectomy/plasty 1 to 3,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4212,Gingivectomy/plasty rest,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4230,Ana crown exp 4 or> per quad,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4231,Ana crown exp 1-3 per quad,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4240,Gingival flap proc w/ planin,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4241,Gngvl flap w rootplan 1-3 th,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4245,Apically positioned flap,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4249,Crown lengthen hard tissue,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4260,Osseous surgery 4 or more,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4261,Osseous surg 1 to 3 teeth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4263,Bone replce graft first site,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4264,Bone replce graft each add,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4265,Bio mtrls to aid soft/os reg,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4266,Guided tiss regen resorble,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4267,Guided tiss regen nonresorb,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4268,Surgical revision procedure,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4270,Pedicle soft tissue graft pr,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4273,Auto tissue graft 1st tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4274,Mesial/distal wedge proc,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4275,Non-auto graft 1st tooth,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4276,Con tissue w dble ped graft,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4277,Soft tissue graft firsttooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4278,Soft tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4283,Auto tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4285,Non-auto graft addl tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4320,Provision splnt intracoronal,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4321,Provisional splint extracoro,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4341,Periodontal scaling & root,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4342,Periodontal scaling 1-3teeth,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4346,Scaling gingiv inflammation,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4355,Full mouth debridement,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4381,Localized delivery antimicro,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4910,Periodontal maint procedures,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4920,Unscheduled dressing change,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4921,Gingival irrigation per quad,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D4999,Unspecified periodontal proc,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5110,Dentures complete maxillary,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5120,Dentures complete mandible,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5130,Dentures immediat maxillary,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5140,Dentures immediat mandible,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5211,Dentures maxill part resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5212,Dentures mand part resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5213,Dentures maxill part metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5214,Dentures mandibl part metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5221,Immed max part denture resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5222,Immed man part denture resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5223,Immed max part dent metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5224,Immed mand part dent metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5225,Maxillary part denture flex,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5226,Mandibular part denture flex,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5281,Removable partial denture,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5282,"Remove unil part denture,max",Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5283,"Remove unil part denture,man",Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5284,Rem unilat dent flex base,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5286,Rem unilat dent 1 pc resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5410,Dentures adjust cmplt maxil,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5411,Dentures adjust cmplt mand,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5421,Dentures adjust part maxill,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5422,Dentures adjust part mandbl,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5510,Dentur repr broken compl bas,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5511,Rep broke comp dent base man,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5512,Rep broke comp dent base max,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5520,Replace denture teeth complt,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5610,Dentures repair resin base,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5611,Rep resin part dent base man,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5612,Rep resin part dent base max,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5620,Rep part denture cast frame,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5621,Rep cast part frame man,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5622,Rep cast part frame max,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5630,Rep partial denture clasp,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5640,Replace part denture teeth,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5650,Add tooth to partial denture,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5660,Add clasp to partial denture,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5670,Replc tth&acrlc on mtl frmwk,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5671,Replc tth&acrlc mandibular,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5710,Dentures rebase cmplt maxil,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5711,Dentures rebase cmplt mand,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5720,Dentures rebase part maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5721,Dentures rebase part mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5730,Denture reln cmplt max dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5731,Denture reln cmplt mand dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5740,Denture reln part max dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5741,Denture reln part mand dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5750,Denture reln cmplt max indir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5751,Denture reln cmplt mand ind,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5760,Denture reln part max indir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5761,Denture reln part mand indir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5810,Denture interm cmplt maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5811,Denture interm cmplt mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5820,Denture interm part maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5821,Denture interm part mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5850,Denture tiss conditn maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5851,Denture tiss condtin mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5862,Precision attachment,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5863,Overdenture complete max,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5864,Overdenture partial max,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5865,Overdenture complete mandib,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5866,Overdenture partial mandib,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5867,Replacement of precision att,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5875,Prosthesis modification,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5876,Add metal sub to acrylc dent,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5899,Removable prosthodontic proc,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5911,Facial moulage sectional,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5912,Facial moulage complete,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5913,Nasal prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5914,Auricular prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5915,Orbital prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5916,Ocular prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5919,Facial prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5922,Nasal septal prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5923,Ocular prosthesis interim,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5924,Cranial prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5925,Facial augmentation implant,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5926,Replacement nasal prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5927,Auricular replacement,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5928,Orbital replacement,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5929,Facial replacement,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5931,Surgical obturator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5932,Postsurgical obturator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5933,Refitting of obturator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5934,Mandibular flange prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5935,Mandibular denture prosth,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5936,Temp obturator prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5937,Trismus appliance,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5951,Feeding aid,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5952,Pediatric speech aid,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5953,Adult speech aid,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5954,Superimposed prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5955,Palatal lift prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5958,Intraoral con def inter plt,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5959,Intraoral con def mod palat,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5960,Modify speech aid prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5982,Surgical stent,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5983,Radiation applicator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5984,Radiation shield,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5985,Radiation cone locator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5986,Fluoride applicator,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5987,Commissure splint,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5988,Surgical splint,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5991,Vesiculobullous disease carr,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5992,Adjust max prost appliance,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5993,Main/clean max prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5994,Peridontal medicament,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5995,"Peri medicament w/seal, max",Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5996,"Peri medicament w/seal, mand",Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D5999,Maxillofacial prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6010,Odontics endosteal implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6011,Second stage implant surgery,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6012,Endosteal implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6013,Surgical place mini implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6040,Odontics eposteal implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6050,Odontics transosteal implnt,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6051,Interim abutment,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6055,Implant connecting bar,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6056,Prefabricated abutment,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6057,Custom abutment,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6058,Abutment supported crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6059,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6060,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6061,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6062,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6063,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6064,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6065,Implant supported crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6066,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6067,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6068,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6069,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6070,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6071,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6072,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6073,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6074,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6075,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6076,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6077,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6080,Implant maintenance,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6081,"Scale & debride, single imp",Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6082,Imp crown porc to base alloy,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6083,Imp crown porc to noble allo,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6084,Imp crown porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6085,Provisional implant crown,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6086,Imp crown base alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6087,Implant crown noble alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6088,Imp crown titanium alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6090,Repair implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6091,Repl semi/precision attach,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6092,Recement supp crown,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6093,Recement supp part denture,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6094,Abut support crown titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6095,Odontics repr abutment,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6096,Remove broken imp ret screw,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6097,Abut crown porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6098,Imp retain porc to base allo,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6099,Imp retainer for fpd,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6100,Removal of implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6101,Debridement of a periimplant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6102,Debridement & contouring,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6103,Bone graft repair perimplant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6104,Bone graft time of implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6110,Implnt/abut remov dent max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6111,Implnt/abut remov dent mand,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6112,Imp/abut rem dent part max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6113,Imp/abut rem dent part mand,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6114,Implnt/abut fixed dent max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6115,Implnt/abut fixed dent mand,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6116,Imp/abut fixed dent part max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6117,Imp/abut fixed dent part man,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6118,Imp/abut int fixed dent man,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6119,Int/abut int fixed dent max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6120,Imp retain porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6121,Retain metal fpd base alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6122,Retain metal fpd noble alloy,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6123,Retain metal fpd titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6190,Radio/surgical implant index,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6191,Semi precision abutment,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6192,Semi precision attachment,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6194,Abut support retainer titani,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6195,Abut retain porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6199,Implant procedure,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6205,Pontic-indirect resin based,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6210,Prosthodont high noble metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6211,Bridge base metal cast,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6212,Bridge noble metal cast,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6214,Pontic titanium,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6240,Bridge porcelain high noble,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6241,Bridge porcelain base metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6242,Bridge porcelain nobel metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6243,Pontic porcelain to titanium,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6245,Bridge porcelain/ceramic,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6250,Bridge resin w/high noble,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6251,Bridge resin base metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6252,Bridge resin w/noble metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6253,Provisional pontic,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6545,Dental retainr cast metl,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6548,Porcelain/ceramic retainer,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6549,Resin retainer,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6600,Porcelain/ceramic inlay 2srf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6601,Porc/ceram inlay >= 3 surfac,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6602,Cst hgh nble mtl inlay 2 srf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6603,Cst hgh nble mtl inlay >=3sr,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6604,Cst bse mtl inlay 2 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6605,Cst bse mtl inlay >= 3 surfa,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6606,Cast noble metal inlay 2 sur,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6607,Cst noble mtl inlay >=3 surf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6608,Onlay porc/crmc 2 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6609,Onlay porc/crmc >=3 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6610,Onlay cst hgh nbl mtl 2 srfc,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6611,Onlay cst hgh nbl mtl >=3srf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6612,Onlay cst base mtl 2 surface,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6613,Onlay cst base mtl >=3 surfa,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6614,Onlay cst nbl mtl 2 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6615,Onlay cst nbl mtl >=3 surfac,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6624,Inlay titanium,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6634,Onlay titanium,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6710,Crown-indirect resin based,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6720,Retain crown resin w hi nble,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6721,Crown resin w/base metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6722,Crown resin w/noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6740,Crown porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6750,Crown porcelain high noble,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6751,Crown porcelain base metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6752,Crown porcelain noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6753,Retain crown porc to titaniu,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6780,Crown 3/4 high noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6781,Crown 3/4 cast based metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6782,Crown 3/4 cast noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6784,Retainer crown 3/4 titanium,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6790,Crown full high noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6791,Crown full base metal cast,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6792,Crown full noble metal cast,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6793,Provisional retainer crown,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6794,Crown titanium,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6920,Dental connector bar,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6930,Recement/bond part denture,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6940,Stress breaker,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6950,Precision attachment,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6980,Fixed partial repair,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6985,Pediatric partial denture fx,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D6999,Fixed prosthodontic proc,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7111,Extraction coronal remnants,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7140,Extraction erupted tooth/exr,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7210,Rem imp tooth w mucoper flp,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7220,Impact tooth remov soft tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7230,Impact tooth remov part bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7240,Impact tooth remov comp bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7241,Impact tooth rem bony w/comp,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7250,Tooth root removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7251,Coronectomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7260,Oral antral fistula closure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7261,Primary closure sinus perf,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7270,Tooth reimplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7272,Tooth transplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7280,Exposure of unerupted tooth,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7282,Mobilize erupted/malpos toot,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7283,Place device impacted tooth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7285,Biopsy of oral tissue hard,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7286,Biopsy of oral tissue soft,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7287,Exfoliative cytolog collect,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7288,Brush biopsy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7290,Repositioning of teeth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7291,Transseptal fiberotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7292,Screw retained plate,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7293,Temp anchorage dev w flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7294,Temp anchorage dev w/o flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7295,"Bone harvest,auto graft proc",Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7296,"Corticotomy, 1-3 teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7297,"Corticotomy, 4 or more teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7310,Alveoplasty w/ extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7311,Alveoloplasty w/extract 1-3,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7320,Alveoplasty w/o extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7321,Alveoloplasty not w/extracts,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7340,Vestibuloplasty ridge extens,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7350,Vestibuloplasty exten graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7410,Rad exc lesion up to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7411,Excision benign lesion>1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7412,Excision benign lesion compl,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7413,Excision malig lesion<=1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7414,Excision malig lesion>1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7415,Excision malig les complicat,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7440,Malig tumor exc to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7441,Malig tumor > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7450,Rem odontogen cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7451,Rem odontogen cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7460,Rem nonodonto cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7461,Rem nonodonto cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7465,Lesion destruction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7471,Rem exostosis any site,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7472,Removal of torus palatinus,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7473,Remove torus mandibularis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7485,Surg reduct osseoustuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7490,Maxilla or mandible resectio,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7510,I&d absc intraoral soft tiss,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7511,Incision/drain abscess intra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7520,I&d abscess extraoral,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7521,Incision/drain abscess extra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7530,Removal fb skin/areolar tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7540,Removal of fb reaction,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7550,Removal of sloughed off bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7560,Maxillary sinusotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7610,Maxilla open reduct simple,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7620,Clsd reduct simpl maxilla fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7630,Open red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7640,Clsd red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7650,Open red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7660,Clsd red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7670,Closd rductn splint alveolus,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7671,Alveolus open reduction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7680,Reduct simple facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7710,Maxilla open reduct compound,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7720,Clsd reduct compd maxilla fx,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7730,Open reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7740,Clsd reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7750,Open red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7760,Clsd red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7770,Open reduc compd alveolus fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7771,Alveolus clsd reduc stblz te,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7780,Reduct compnd facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7810,Tmj open reduct-dislocation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7820,Closed tmp manipulation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7830,Tmj manipulation under anest,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7840,Removal of tmj condyle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7850,Tmj meniscectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7852,Tmj repair of joint disc,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7854,Tmj excisn of joint membrane,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7856,Tmj cutting of a muscle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7858,Tmj reconstruction,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7860,Tmj cutting into joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7865,Tmj reshaping components,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7870,Tmj aspiration joint fluid,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7871,Lysis + lavage w catheters,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7872,Tmj diagnostic arthroscopy,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7873,Tmj arthroscopy lysis adhesn,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7874,Tmj arthroscopy disc reposit,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7875,Tmj arthroscopy synovectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7876,Tmj arthroscopy discectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7877,Tmj arthroscopy debridement,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7880,Occlusal orthotic appliance,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7881,Occ orthotic device adjust,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7899,Tmj unspecified therapy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7910,Dent sutur recent wnd to 5cm,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7911,Dental suture wound to 5 cm,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7912,Suture complicate wnd > 5 cm,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7920,Dental skin graft,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7921,Collect & appl blood product,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7922,Place intra-socket bio dress,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7940,Reshaping bone orthognathic,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7941,Bone cutting ramus closed,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7943,Cutting ramus open w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7944,Bone cutting segmented,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7945,Bone cutting body mandible,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7946,Reconstruction maxilla total,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7947,Reconstruct maxilla segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7948,Reconstruct midface no graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7949,Reconstruct midface w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7950,Mandible graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7951,Sinus aug w bone or bone sub,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7952,Sinus augmentation vertical,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7953,Bone replacement graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7955,Repair maxillofacial defects,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7960,Frenulectomy/frenectomy,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7961,Buccal/labial frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7962,Lingual frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7963,Frenuloplasty,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7970,Excision hyperplastic tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7971,Excision pericoronal gingiva,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7972,Surg redct fibrous tuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7979,Non-surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7980,Surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7981,Excision of salivary gland,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7982,Sialodochoplasty,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7983,Closure of salivary fistula,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7990,Emergency tracheotomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7991,Dental coronoidectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7993,Surg place craniofacial impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7994,Surg place zygomatic impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7995,Synthetic graft facial bones,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7996,Implant mandible for augment,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7997,Appliance removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7998,Intraoral place of fix dev,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D7999,Oral surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8010,Limited dental tx primary,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8020,Limited dental tx transition,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8030,Limited dental tx adolescent,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8040,Limited dental tx adult,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8050,Intercep dental tx primary,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8060,Intercep dental tx transitn,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8070,Compre dental tx transition,Dental,Per Unit,$195.04 ,OP,$195.04 ,$195.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8080,Compre dental tx adolescent,Dental,Per Unit,$195.04 ,OP,$195.04 ,$195.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8090,Compre dental tx adult,Dental,Per Unit,$195.04 ,OP,$195.04 ,$195.04 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8210,Orthodontic rem appliance tx,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8220,Fixed appliance therapy habt,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8660,Preorthodontic tx visit,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8670,Periodic orthodontc tx visit,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8680,Orthodontic retention,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8681,Removable retainer adjust,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8690,Orthodontic treatment,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8691,Repair ortho appliance,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8692,Replacement retainer,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8693,Rebond/recement retainers,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8694,Repair fixed retainers,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8695,Remove fixed ortho appliance,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8696,Rep of ortho appliance max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8697,Rep of ortho appliance man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8698,Recement fixed retainer max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8699,Recement fixed retainer man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8701,Repair fixed retainer max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8702,Repair of fixed retainer man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8703,Replace broken retainer max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8704,Replace broken retainer man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D8999,Orthodontic procedure,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9110,Tx dental pain minor proc,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9120,Fix partial denture section,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9130,Temporomandibular joint dysf,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9210,Dent anesthesia w/o surgery,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9211,Regional block anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9212,Trigeminal block anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9215,Local anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9219,Eval mod/deep sed/gen anest,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9220,General anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9221,General anesthesia ea ad 15m,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9222,"Deep anest, 1st 15 min",Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9223,General anesth ea addl 15 mi,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9230,Analgesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9239,"Iv mod sedation, 1st 15 min",Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9241,Intravenous sedation,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9242,Iv sedation ea ad 15 m,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9243,Iv sedation ea addl 15m,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9248,Sedation (non-iv),Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9310,Dental consultation,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9311,Consult w/med hlth care prof,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9410,Dental house call,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9420,Hospital/asc call,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9430,Office visit during hours,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9440,Office visit after hours,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9450,Case presentation tx plan,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9610,Dent therapeutic drug inject,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9612,Thera par drugs 2 or > admin,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9613,Infiltration thera drug,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9630,Drugs/meds disp for home use,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9910,Dent appl desensitizing med,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9911,Appl desensitizing resin,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9920,Behavior management,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9930,Treatment of complications,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9931,Clean/inspect rem appliance,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9932,Clean & inspect rem dent max,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9933,Clean & inspect rem dent man,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9934,Clean rem part denture max,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9935,Clean rem part denture mand,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9940,Dental occlusal guard,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9941,Fabrication athletic guard,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9942,Repair/reline occlusal guard,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9943,Occlusal guard adjustment,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9944,"Occ guard, hard, full arch",Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9945,"Occ guard, soft, full arch",Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9946,"Occ guard, hard, part arch",Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9950,Occlusion analysis,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9951,Limited occlusal adjustment,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9952,Complete occlusal adjustment,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9970,Enamel microabrasion,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9971,Odontoplasty per tooth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9972,Extrnl bleaching per arch,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9973,Extrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9974,Intrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9975,External bleaching home app,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9991,"Case mgmt, appt barriers",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9992,"Case mgmt, care coordination",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9993,"Case mgmt, interviewing",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9994,"Case mgmt, pt education",Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9995,Teledentistry real-time,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9996,Teledentistry dent review,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9997,Dent case mgmt special needs,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,D9999,Adjunctive procedure,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0008,Admin influenza virus vac,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0009,Admin pneumococcal vaccine,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0010,Admin hepatitis b vaccine,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0027,Semen analysis,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0068,Adm iv infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0069,Adm sq infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0070,Adm of chemo drug in home,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0071,Comm svcs by rhc/fqhc 5 min,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0076,Care manag h vst new pt 20 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0077,Care manag h vst new pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0078,Care manag h vst new pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0079,Care manag h vst new pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0080,Care manag h vst new pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0081,Care man h v ext pt 20 mi,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0082,Care man h v ext pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0083,Care man h v ext pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0084,Care man h v ext pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0085,Care man h v ext pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0086,Care man home care plan 30 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0087,Care man home care plan 60 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0088,Adm iv drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0089,Adm subq drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0090,Adm iv chemo 1st home visit,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0103,Psa screening,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0104,Ca screen;flexi sigmoidscope,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0105,Colorectal scrn; hi risk ind,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0108,Diab manage trn per indiv,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0109,Diab manage trn ind/group,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0117,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0118,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0121,Colon ca scrn not hi rsk ind,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0122,Colon ca scrn; barium enema,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0123,Screen cerv/vag thin layer,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0124,Screen c/v thin layer by md,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0127,Trim nail(s),General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0128,Corf skilled nursing service,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0130,Single energy x-ray study,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0141,"Scr c/v cyto,autosys and md",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0143,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0144,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0145,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0147,"Scr c/v cyto, automated sys",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0148,"Scr c/v cyto, autosys, rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0151,"Hhcp-serv of pt,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0152,"Hhcp-serv of ot,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0153,"Hhcp-svs of s/l path,ea 15mn",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0155,"Hhcp-svs of csw,ea 15 min",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0157,Hhc pt assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0158,Hhc ot assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0159,Hhc pt maint ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0160,Hhc occup therapy ea 15,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0161,Hhc slp ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0162,"Hhc rn e&m plan svs, 15 min",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0166,"Extrnl counterpulse, per tx",Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0175,"Opps service,sched team conf",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0176,Opps/php;activity therapy,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0177,Opps/php; train & educ serv,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0179,Md recertification hha pt,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0180,Md certification hha patient,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0181,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0182,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0186,"Dstry eye lesn,fdr vssl tech",Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0202,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0204,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0206,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0219,Pet img wholbod melano nonco,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0235,Pet not otherwise specified,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0237,Therapeutic procd strg endur,Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0238,"Oth resp proc, indiv",Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0239,"Oth resp proc, group",Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0248,Demonstrate use home inr mon,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0252,Pet imaging initial dx,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0255,Current percep threshold tst,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0257,Unsched dialysis esrd pt hos,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0270,Mnt subs tx for change dx,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0271,Group mnt 2 or more 30 mins,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0278,"Iliac art angio,cardiac cath",Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G0279,"Tomosynthesis, mammo",Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0283,Elec stim other than wound,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0289,"Arthro, loose body + chondro",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G0293,"Non-cov surg proc,clin trial",Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0297,Ldct for lung ca screen,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0306,Cbc/diffwbc w/o platelet,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0307,Cbc without platelet,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0328,Fecal blood scrn immunoassay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0339,"Robot lin-radsurg com, first",Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G0340,Robt lin-radsurg fractx 2-5,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G0365,Vessel mapping hemo access,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0378,Hospital observation per hr,Ancillary Services,Per Unit,$651.20 ,OP,$651.20 ,$651.20 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0389,Ultrasound exam aaa screen,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0396,Alcohol/subs interv 15-30mn,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0397,Alcohol/subs interv >30 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0403,Ekg for initial prevent exam,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0404,Ekg tracing for initial prev,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0405,Ekg interpret & report preve,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0409,Corf related serv 15 mins ea,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0410,Grp psych partial hosp 45-50,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0411,Inter active grp psych parti,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0412,Open tx iliac spine uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G0413,Pelvic ring fracture uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G0414,Pelvic ring fx treat int fix,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G0415,Open tx post pelvic fxcture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G0420,Ed svc ckd ind per session,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0421,Ed svc ckd grp per session,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0422,Intens cardiac rehab w/exerc,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0423,Intens cardiac rehab no exer,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0424,Pulmonary rehab w exer,Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0431,Drug screen multiple class,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0432,Eia hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0433,Elisa hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0434,Drug screen multi drug class,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0435,Oral hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0436,Tobacco-use counsel 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0437,Tobacco-use counsel>10min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0442,Annual alcohol screen 15 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0443,Brief alcohol misuse counsel,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0444,Depression screen annual,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0445,High inten beh couns std 30m,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0446,Intens behave ther cardio dx,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0447,Behavior counsel obesity 15m,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0448,Place perm pacing cardiovert,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G0451,Devlopment test interpt&rep,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0452,Molecular pathology interpr,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0459,Telehealth inpt pharm mgmt,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0464,"Colorec CA scr, sto bas DNA",Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0472,Hep c screen high risk/other,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0473,Group behave couns 2-10,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0475,Hiv combination assay,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0476,Hpv combo assay ca screen,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0477,Drug test presump optical,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0478,Drug test presump opt inst,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0479,Drug test presump not opt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0480,Drug test def 1-7 classes,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0491,Dialysis acu kidney no esrd,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0492,Md/oth eval acut kid no esrd,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0495,Rn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0496,Lpn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0498,Chemo extend iv infus w/pump,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0499,Hepb screen high risk indiv,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0500,Mod sedat endo service >5yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0502,"Init psych care manag, 70min",Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0503,"Subseq psych care man,60mi",Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0504,Init/sub psych care add 30 m,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0506,Comp asses care plan ccm svc,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0507,Care manage serv minimum 20,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0511,Ccm/bhi by rhc/fqhc 20min mo,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0512,Cocm by rhc/fqhc 60 min mo,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0515,Cognitive skills development,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0516,"Insert drug del implant, >=4",General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0517,Remove drug implant,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0518,Remove w insert drug implant,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G0659,Drug test def simple all cl,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2000,Blinded conv. tx mdd clin tr,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2010,Remot image submit by pt,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2011,Alcohol/sub misuse assess,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2012,Brief check in by md/qhp,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2014,Post-d/c care plan overs 30m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2015,Post-d/c care plan overs 60m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2058,Ccm add 20min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2064,Md mang high risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2065,Clin mang h risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2066,Inter devc remote 30d,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2082,Visit esketamine 56m or less,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2083,"Visit esketamine, > 56m",Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2168,Svs by pt in home health,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2169,Svs by ot in home health,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2213,Initiat med assist tx in er,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2214,Init/sub psych care m 1st 30,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2250,"Remot img sub by pt, non e/m",Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2251,"Brief chkin, 5-10, non-e/m",Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G2252,"Brief chkin by md/qhp, 11-20",Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G3001,"Admin + supply, tositumomab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6001,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6002,Stereoscopic x-ray guidance,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6003,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6004,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6005,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6006,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6007,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6008,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6009,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6010,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6011,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6012,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6013,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6014,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6015,Radiation tx delivery imrt,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6016,Delivery comp imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6018,Ileoscopy w/stent,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Meridian Medicaid,CPT,G6019,Colonoscopy lesion removal,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6020,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6021,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6022,Sigmoidoscopy w/ablate tumr,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6023,Sigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6024,Lesion removal colonoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6025,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6027,Anoscopy hra w/spec collect,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6028,Anoscopy hra w/biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6030,Assay of amitriptyline,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6031,Assay of benzodiazepines,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6032,Assay of desipramine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6034,Assay of doxepin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6035,Assay of gold,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6036,Assay of Imipramine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6037,Assay of nortiptyline,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6038,Assay of salicylate,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6039,Assay of acetaminophen,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6040,Assay of ethanol,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6041,Assay of urine alkaloids,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6042,Assay of amphetamines,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6043,Assay of barbiturates,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6044,Assay of cocaine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6045,Assay of dihydrocodeinone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6046,Assay of dihydromorphinone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6047,Assay of dihydrotestosterone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6048,Assay of dimethadione,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6049,Assay of Epiandrosterone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6050,Assay of Ethchlorvynol,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6051,Assay of flurazepam,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6052,Assay of meprobamate,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6053,Assay of methadone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6054,Assay of methsuximide,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6055,Assay of nicotine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6056,Assay of opiates,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6057,Assay of phenothiazine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G6058,Drug confirmation,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9012,Other specified case mgmt,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9016,Demo-smoking cessation coun,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9020,Rimantadine hcl 100mg oral,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9034,"Zanamivir, inh pwdr, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9035,"Oseltamivir phosp, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9143,Warfarin respon genetic test,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9147,Outpt iv insulin tx any mea,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9157,Transesoph doppl cardiac mon,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9187,Bpci home visit,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9477,Care coord at hospice,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9686,Nursing facility conference,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9873,1 em core session,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9874,4 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9875,9 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9876,2 em core ms mo 7-9 no wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9877,2 em core ms mo 10-12 no wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9878,2 em core ms mo 7-9 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9879,2 em core ms mo 10-12 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9880,Em 5 percent wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9881,Em 9 percent wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9882,2 em ongoing ms mo 13-15 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9883,2 em ongoing ms mo 16-18 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9884,2 em ongoing ms mo 19-21 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9885,2 em ongoing ms mo 22-24 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9890,Em bridge payment,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,G9987,Bpci advanced in home visit,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0001,Alcohol and/or drug assess,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0002,Alcohol and/or drug screenin,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0003,Alcohol and/or drug screenin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0004,Alcohol and/or drug services,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0005,Alcohol and/or drug services,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0006,Alcohol and/or drug services,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0007,Alcohol and/or drug services,Behavioral Health,Per Unit,$135.70 ,OP,$135.70 ,$135.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0014,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0015,Alcohol and/or drug services,Behavioral Health,Per Unit,$339.88 ,OP,$339.88 ,$339.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0020,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0022,Alcohol and/or drug interven,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0031,Mh health assess by non-md,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0032,Mh svc plan dev by non-md,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0033,Oral med adm direct observe,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0034,Med trng & support per 15min,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0035,Mh partial hosp tx under 24h,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0037,Comm psy sup tx pgm per diem,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0046,"Mental health service, nos",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0047,Alcohol/drug abuse svc nos,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0049,Alcohol/drug screening,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H0050,Alcohol/drug service 15 min,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H1002,Carecoordination prenatal,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H1003,Prenatal at risk education,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H1011,Family assessment,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2000,Comp multidisipln evaluation,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2001,Rehabilitation program 1/2 d,Behavioral Health,Per Unit,$166.94 ,OP,$166.94 ,$166.94 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2010,Comprehensive med svc 15 min,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2011,"Crisis interven svc, 15 min",Behavioral Health,Per Unit,$135.70 ,OP,$135.70 ,$135.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2012,"Behav hlth day treat, per hr",Behavioral Health,Per Unit,$276.34 ,OP,$276.34 ,$276.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2014,"Skills train and dev, 15 min",Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2017,"Psysoc rehab svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2018,"Psysoc rehab svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2019,"Ther behav svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2020,"Ther behav svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2027,"Psychoed svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2028,"Sex offend tx svc, 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2029,"Sex offend tx svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2032,"Activity therapy, per 15 min",Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2033,Multisys ther/juvenile 15min,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2035,"A/d tx program, per hour",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,H2036,"A/d tx program, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0121,"Inj., omadacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0122,"Inj., eravacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0129,Abatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0130,Abciximab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0135,Adalimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0178,Aflibercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0179,"Inj, brolucizumab-dbll, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0180,Agalsidase beta injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0185,"Inj., aprepitant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0202,"Injection, alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0205,Alglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0207,Amifostine,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0210,Methyldopate hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0215,Alefacept,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0220,Alglucosidase alfa injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0221,Lumizyme injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0222,"Inj., patisiran, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0223,Inj givosiran 0.5 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0256,Alpha 1 proteinase inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0257,Glassia injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0287,Amphotericin b lipid complex,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0288,Ampho b cholesteryl sulfate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0289,Amphotericin b liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0291,"Inj., plazomicin, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0348,Anidulafungin injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0350,Injection anistreplase 30 u,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0364,Apomorphine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0365,"Aprotonin, 10,000 kiu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0401,Inj aripiprazole ext rel 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0475,Baclofen 10 mg injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0480,Basiliximab,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0485,Belatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0490,Belimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0517,"Inj., benralizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0558,Peng benzathine/procaine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0561,Penicillin g benzathine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0565,"Inj, bezlotoxumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0567,"Inj., cerliponase alfa 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0570,Buprenorphine implant 74.2mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0583,Bivalirudin,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0584,"Injection, burosumab-twza 1m",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0585,"Injection,onabotulinumtoxina",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0586,Abobotulinumtoxina,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0587,"Inj, rimabotulinumtoxinb",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0588,Incobotulinumtoxin a,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0591,"Inj deoxycholic acid, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0593,"Inj., lanadelumab-flyo, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0594,Busulfan injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0596,"Injection, ruconest",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0597,"C-1 esterase, berinert",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0598,"C-1 esterase, cinryze",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0599,"Inj., haegarda 10 units",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0600,Edetate calcium disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0604,"Cinacalcet, esrd on dialysis",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0606,"Inj, etelcalcetide, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0630,Calcitonin salmon injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0637,Caspofungin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0638,Canakinumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0641,Inj levoleucovorin nos 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0642,"Injection, khapzory, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0691,Inj lefamulin 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0693,"Inj., cefiderocol, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0695,Inj ceftolozane tazobactam,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0712,Ceftaroline fosamil inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0714,Ceftazidime and avibactam,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0716,Centruroides immune f(ab),Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0717,Certolizumab pegol inj 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0740,Cidofovir injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0775,"Collagenase, clost hist inj",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0791,Inj crizanlizumab-tmca 5mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0795,Corticorelin ovine triflutal,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0800,Corticotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0833,Cosyntropin injection nos,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0840,Crotalidae poly immune fab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0841,Inj crotalidae im f(ab')2 eq,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0850,Cytomegalovirus imm iv /vial,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0875,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0878,Daptomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0881,"Darbepoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0882,"Darbepoetin alfa, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0883,Argatroban nonesrd use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0884,Argatroban esrd dialysis 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0885,"Epoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0886,Epoetin alfa 1000 units esrd,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0890,Peginesatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0894,Decitabine injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J0896,Inj luspatercept-aamt 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J0897,Denosumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1095,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1096,Dexametha opth insert 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1097,Phenylep ketorolac opth soln,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1162,Digoxin immune fab (ovine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1190,Dexrazoxane hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1201,Inj. cetirizine hcl 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1205,Chlorothiazide sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1267,Doripenem injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1290,Ecallantide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1300,Eculizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1301,"Injection, edaravone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1303,"Inj., ravulizumab-cwvz 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1322,"Elosulfase alfa, injection",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1327,Eptifibatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1410,Inj estrogen conjugate 25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1428,"Inj, eteplirsen, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1429,Inj golodirsen 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1430,Ethanolamine oleate 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1436,Etidronate disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1437,Inj. fe derisomaltose 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1438,Etanercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1439,Inj ferric carboxymaltos 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1442,Inj filgrastim excl biosimil,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1446,"Inj, tbo-filgrastim, 5 mcg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1447,Inj tbo filgrastim 1 microg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1451,"Fomepizole, 15 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1452,Intraocular fomivirsen na,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1453,Fosaprepitant injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1454,"Inj fosnetupitant, palonoset",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1455,Foscarnet sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1457,Gallium nitrate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1458,Galsulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1459,Inj ivig privigen 500 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1460,Gamma globulin 1 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1555,"Inj cuvitru, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1556,"Inj, imm glob bivigam, 500mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1557,Gammaplex injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1558,"Inj. xembify, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1559,Hizentra injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1560,Gamma globulin > 10 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1561,Gamunex-c/gammaked,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1562,"Vivaglobin, inj",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1566,"Immune globulin, powder",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1568,Octagam injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1569,Gammagard liquid injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1570,Ganciclovir sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1571,Hepagam b im injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1572,Flebogamma injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1573,"Hepagam b intravenous, inj",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1575,Hyqvia 100mg immuneglobulin,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1595,Injection glatiramer acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1599,"Ivig non-lyophilized, nos",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1602,Golimumab for iv use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1610,Glucagon hydrochloride/1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1628,"Inj., guselkumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1632,"Inj., brexanolone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1640,"Hemin, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1670,Tetanus immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1675,Histrelin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1738,Inj. meloxicam 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1740,Ibandronate sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1742,Ibutilide fumarate injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1743,Idursulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1744,Icatibant injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1745,Infliximab not biosimil 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1746,"Inj., ibalizumab-uiyk, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1750,Inj iron dextran,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1756,Iron sucrose injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1786,Imuglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1823,"Inj. inebilizumab-cdon, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1826,Interferon beta-1a inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1830,Interferon beta-1b / .25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1833,"Injection, isavuconazonium",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1930,Lanreotide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1931,Laronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J1942,Aripiprazole lauroxil 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1943,"Inj., aristada initio, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1944,Aripirazole lauroxil 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1945,Lepirudin,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J1950,Leuprolide acetate /3.75 mg,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2062,Loxapine for inhalation 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2170,Mecasermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2182,"Injection, mepolizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2186,"Inj., meropenem, vaborbactam",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2248,Micafungin sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2278,Ziconotide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2315,"Naltrexone, depot form",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2323,Natalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2325,Nesiritide injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2326,"Inj, nusinersen, 0.1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2350,"Injection, ocrelizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2353,"Octreotide injection, depot",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2355,Oprelvekin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2357,Omalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2407,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2425,Palifermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2426,Paliperidone palmitate inj,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2469,Palonosetron hcl,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2502,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2503,Pegaptanib sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2504,"Pegademase bovine, 25 iu",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2505,"Injection, pegfilgrastim 6mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2507,Pegloticase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2513,Pentastarch 10% solution,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2515,Pentobarbital sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2545,Pentamidine non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2547,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2562,Plerixafor injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2597,Inj desmopressin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2724,Protein c concentrate,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2730,Pralidoxime chloride inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2770,Quinupristin/dalfopristin,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2778,Ranibizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2783,Rasburicase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2786,"Injection, reslizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2790,Rho d immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2791,Rhophylac injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2792,"Rho(d) immune globulin h, sd",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2793,Rilonacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2794,"Inj risperdal consta, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2796,Romiplostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2797,"Inj., rolapitant, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2798,"Inj., perseris, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2805,Sincalide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2820,Sargramostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2840,Inj sebelipase alfa 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2850,Inj secretin synthetic human,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J2860,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2993,Reteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J2997,Alteplase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3031,"Inj., fremanezumab-vfrm 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3060,"Inj, taliglucerase alfa 10 u",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3090,Inj tedizolid phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3095,Telavancin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3101,Tenecteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3110,Teriparatide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3111,Inj. romosozumab-aqqg 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3145,Testosterone undecanoate 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3240,Thyrotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3241,Inj. teprotumumab-trbw 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3243,Tigecycline injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3245,"Inj., tildrakizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3246,Tirofiban hcl,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3262,Tocilizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3285,Treprostinil injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3300,Triamcinolone a inj prs-free,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3304,Inj triamcinolone ace xr 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3315,Triptorelin pamoate,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3316,"Inj., triptorelin xr 3.75 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3355,"Urofollitropin, 75 iu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3357,"Ustekinumab sub cu inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3358,"Ustekinumab, iv inject, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3365,"Urokinase 250,000 iu inj",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3380,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3385,Velaglucerase alfa,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3396,Verteporfin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3397,"Inj., vestronidase alfa-vjbk",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3398,Inj luxturna 1 billion vec g,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3399,Inj onase abepar-xioi treat,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J3470,Hyaluronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3471,"Ovine, up to 999 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3472,"Ovine, 1000 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J3473,Hyaluronidase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7169,"Inj andexxa, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7170,"Inj., emicizumab-kxwh 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7175,"Inj, factor x, (human), 1iu",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7177,"Inj., fibryga, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7178,Inj human fibrinogen con nos,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7179,Vonvendi inj 1 iu vwf:rco,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7180,Factor xiii anti-hem factor,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7181,Factor xiii recomb a-subunit,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7182,Factor viii recomb novoeight,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7183,Wilate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7185,Xyntha inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7186,Antihemophilic viii/vwf comp,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7187,"Humate-p, inj",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7188,Factor viii recomb obizur,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7189,Factor viia recomb novoseven,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7190,Factor viii,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7191,Factor viii (porcine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7192,Factor viii recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7193,Factor ix non-recombinant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7194,Factor ix complex,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7195,Factor ix recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7196,Antithrombin recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7197,Antithrombin iii injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7198,Anti-inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7199,Hemophilia clot factor noc,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7200,Factor ix recombinan rixubis,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7201,Factor ix alprolix recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7202,Factor ix idelvion inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7203,Factor ix recomb gly rebinyn,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7204,Inj recombin esperoct per iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7205,Factor viii fc fusion recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7207,Factor viii pegylated recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7208,Inj. jivi 1 iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7209,Factor viii nuwiq recomb 1iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7210,"Inj, afstyla, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7211,"Inj, kovaltry, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7212,Factor viia recomb sevenfact,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7296,"Kyleena, 19.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7297,"Liletta, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7298,"Mirena, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7300,Intraut copper contraceptive,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7301,"Skyla, 13.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7302,Levonorgestrel iu 52 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7303,Contraceptive vaginal ring,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7304,Contraceptive hormone patch,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7306,Levonorgestrel implant sys,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7307,Etonogestrel implant system,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7308,Aminolevulinic acid hcl top,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7309,"Methyl aminolevulinate, top",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7310,Ganciclovir long act implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7311,"Inj., retisert, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7312,Dexamethasone intra implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7313,"Inj., iluvien, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7314,"Inj., yutiq, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7315,Ophthalmic mitomycin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7316,"Inj, ocriplasmin, 0.125 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7318,"Inj, durolane 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7320,"Genvisc 850, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7321,Hyalgan or supartz inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7322,Hymovis injection 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7323,Euflexxa inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7324,Orthovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7325,Synvisc or synvisc-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7326,Gel-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7327,Monovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7328,Gelsyn-3 injection 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7329,"Inj, trivisc 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7330,Cultured chondrocytes implnt,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7331,"Synojoynt, inj., 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7332,"Inj., triluron, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7333,Visco-3 inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7336,Capsaicin 8% patch,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7340,Carbidopa levodopa ent 100ml,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7345,"Aminolevulinic acid, 10% gel",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7351,Inj bimatoprost itc imp1mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7352,"Afamelanotide implant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7401,Mometasone furoate sinus imp,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7501,Azathioprine parenteral,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7504,Lymphocyte immune globulin,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J7505,Monoclonal antibodies,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7511,Antithymocyte globuln rabbit,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7513,"Daclizumab, parenteral",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7525,Tacrolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7639,Dornase alfa non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7685,Tobramycin comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J7686,"Treprostinil, non-comp unit",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J8501,Oral aprepitant,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J8560,Etoposide oral 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J8562,Oral fludarabine phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J8565,Gefitinib oral,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J8655,"Oral netupitant, palonosetro",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J8670,"Rolapitant, oral, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J8705,Topotecan oral,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9010,Alemtuzumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9015,Aldesleukin injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9017,Arsenic trioxide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9019,Erwinaze injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9020,"Asparaginase, nos",Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9022,"Inj, atezolizumab,10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9023,"Injection, avelumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9025,Azacitidine injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9027,Clofarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9030,Bcg live intravesical 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9031,Bcg live intravesical vac,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9032,"Injection, belinostat, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9033,"Inj., treanda 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9034,"Inj., bendeka 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9035,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9036,Inj. belrapzo/bendamustine,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9039,"Injection, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9040,Bleomycin sulfate injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9041,"Inj., velcade 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9042,Brentuximab vedotin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9043,Cabazitaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9044,"Inj, bortezomib, nos, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9047,"Injection, carfilzomib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9050,Carmustine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9055,Cetuximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9057,"Inj., copanlisib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9065,Inj cladribine per 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9070,Cyclophosphamide 100 mg inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9098,Cytarabine liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9118,Inj. calaspargase pegol-mknl,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9119,"Inj., cemiplimab-rwlc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9120,Dactinomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9144,"Daratumumab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9145,"Injection, daratumumab 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9150,Daunorubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9151,Daunorubicin citrate inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9153,"Inj daunorubicin, cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9155,Degarelix injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9160,Denileukin diftitox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9171,Docetaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9173,"Inj., durvalumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9176,"Injection, elotuzumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9179,Eribulin mesylate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9185,Fludarabine phosphate inj,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9198,"Inj. infugem, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9199,"Injection, infugem, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9200,Floxuridine injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9202,Goserelin acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9204,"Inj mogamulizumab-kpkc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9205,Inj irinotecan liposome 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9207,Ixabepilone injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9208,Ifosfamide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9210,"Inj., emapalumab-lzsg, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9211,Idarubicin hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9213,Interferon alfa-2a inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9214,Interferon alfa-2b inj,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9216,Interferon gamma 1-b inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9217,Leuprolide acetate suspnsion,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9219,Leuprolide acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9223,"Inj. lurbinectedin, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9225,Vantas implant,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9226,Supprelin la implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9227,Inj. isatuximab-irfc 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9228,Ipilimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9230,Mechlorethamine hcl inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9245,Inj melpha hydroch nos 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9246,"Inj., evomela, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9261,Nelarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9262,"Inj, omacetaxine mep, 0.01mg",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9264,Paclitaxel protein bound,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9266,Pegaspargase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9268,Pentostatin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9270,Plicamycin (mithramycin) inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9271,Inj pembrolizumab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9280,Mitomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9281,Mitomycin instillation,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9285,"Inj, olaratumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9293,Mitoxantrone hydrochl / 5 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9295,"Injection, necitumumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9299,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9300,Gemtuzumab ozogamicin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9301,Obinutuzumab inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9302,Ofatumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9303,Panitumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9304,"Inj. pemetrexed, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9305,Inj. pemetrexed nos 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9306,"Injection, pertuzumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9307,Pralatrexate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9308,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9309,"Inj, polatuzumab vedotin 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9310,Rituximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9311,"Inj rituximab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9312,"Inj., rituximab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9313,"Inj., lumoxiti, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9315,Romidepsin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9316,"Pertuzu, trastuzu, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9317,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9320,Streptozocin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9325,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9328,Temozolomide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9330,Temsirolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9340,Thiotepa injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9352,Injection trabectedin 0.1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9354,"Inj, ado-trastuzumab emt 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9355,Inj trastuzumab excl biosimi,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9356,"Inj. herceptin hylecta, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9357,Valrubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9358,Inj fam-trastu deru-nxki 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9371,"Inj, vincristine sul lip 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,J9395,"Injection, fulvestrant",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9400,"Inj, ziv-aflibercept, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,J9600,Porfimer sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,L8604,Dextranomer/hyaluronic acid,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,L8605,Inj bulking agent anal canal,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,L8607,Inj vocal cord bulking agent,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,M0239,Bamlanivimab-xxxx infusion,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,M0243,Casirivi and imdevi infusion,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P2028,Cephalin floculation test,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P2029,Congo red blood test,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P2031,Hair analysis,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P2033,Blood thymol turbidity,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P2038,Blood mucoprotein,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P3000,Screen pap by tech w md supv,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P3001,Screening pap smear by phys,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P7001,Culture bacterial urine,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9010,Whole blood for transfusion,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9011,Blood split unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9012,Cryoprecipitate each unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9016,Rbc leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9017,Plasma 1 donor frz w/in 8 hr,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9019,"Platelets, each unit",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9020,Plaelet rich plasma unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9021,Red blood cells unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9022,Washed red blood cells unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9023,"Frozen plasma, pooled, sd",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9031,Platelets leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9032,"Platelets, irradiated",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9033,Platelets leukoreduced irrad,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9034,"Platelets, pheresis",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9035,Platelet pheres leukoreduced,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9036,Platelet pheresis irradiated,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9037,Plate pheres leukoredu irrad,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9038,Rbc irradiated,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9039,Rbc deglycerolized,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9040,Rbc leukoreduced irradiated,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9041,"Albumin (human),5%, 50ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9043,"Plasma protein fract,5%,50ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9044,Cryoprecipitatereducedplasma,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9045,"Albumin (human), 5%, 250 ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9046,"Albumin (human), 25%, 20 ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9047,"Albumin (human), 25%, 50ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9048,"Plasmaprotein fract,5%,250ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9050,"Granulocytes, pheresis unit",Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Meridian Medicaid,CPT,P9051,"Blood, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9052,"Platelets, hla-m, l/r, unit",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9053,"Plt, pher, l/r cmv-neg, irr",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9054,"Blood, l/r, froz/degly/wash",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9055,"Plt, aph/pher, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9056,"Blood, l/r, irradiated",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9057,"Rbc, frz/deg/wsh, l/r, irrad",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9058,"Rbc, l/r, cmv-neg, irrad",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9059,"Plasma, frz between 8-24hour",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9060,Fr frz plasma donor retested,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9070,Pathogen reduced plasma pool,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9071,Pathogen reduced plasma sing,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9072,Plate path red/rapid bac tes,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9073,Platelets pheresis path redu,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9099,Blood component/product noc,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,P9100,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0035,Cardiokymography,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0081,Infusion ther other than che,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0084,Chemotherapy by infusion,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0085,Chemo by both infusion and o,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0091,Obtaining screen pap smear,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0111,Wet mounts/ w preparations,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0112,Potassium hydroxide preps,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0113,Pinworm examinations,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0114,Fern test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0115,Post-coital mucous exam,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0138,"Ferumoxytol, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0139,"Ferumoxytol, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0239,Bamlanivimab-xxxx,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0243,Casirivimab and imdevimab,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q0515,Sermorelin acetate injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q2017,"Teniposide, 50 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q2028,"Inj, sculptra, 0.5mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q2034,Agriflu vaccine,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q2035,"Afluria vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q2036,"Flulaval vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q2037,"Fluvirin vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q2038,"Fluzone vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q2039,"Influenza virus vaccine, nos",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q2040,Tisagenlecleucel car-pos t,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q2043,Sipuleucel-t auto cd54+,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q2049,Imported lipodox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q2050,Doxorubicin inj 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q3014,Telehealth facility fee,Ancillary Services,Per Unit,$8.33 ,OP,$8.33 ,$8.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q3027,Inj beta interferon im 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q3028,Inj beta interferon sq 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4074,Iloprost non-comp unit dose,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4081,"Epoetin alfa, 100 units esrd",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4100,"Skin substitute, nos",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4101,Apligraf,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4102,Oasis wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4103,Oasis burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4104,Integra bmwd,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4105,Integra drt or omnigraft,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4106,Dermagraft,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4107,Graftjacket,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4108,Integra matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4110,Primatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4111,Gammagraft,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4112,Cymetra injectable,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4113,Graftjacket xpress,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4114,Integra flowable wound matri,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4115,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4116,Alloderm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4117,Hyalomatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4118,Matristem micromatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4119,Matristem wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4120,Matristem burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4121,Theraskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4122,"Dermacell, awm, porous sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4123,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4124,Oasis tri-layer wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4125,Arthroflex,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4126,Memoderm/derma/tranz/integup,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4127,Talymed,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4128,Flexhd/allopatchhd/matrixhd,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4129,Unite biomatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4130,Strattice tm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4131,Epifix or epicord,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4132,"Grafix core, grafixpl core",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4133,Grafix stravix prime pl sqcm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4134,Hmatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4135,Mediskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4136,Ezderm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4137,Amnioexcel biodexcel 1sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4138,"Biodfence dryflex, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4139,"Amnio or biodmatrix, inj 1cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4140,Biodfence 1cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4141,"Alloskin ac, 1 cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4142,Xcm biologic tiss matrix 1cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4143,"Repriza, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4145,"Epifix, inj, 1mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4146,"Tensix, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4147,Architect ecm px fx 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4148,Neox neox rt or clarix cord,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4149,"Excellagen, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4150,Allowrap ds or dry 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4151,"Amnioband, guardian 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4152,Dermapure 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4153,"Dermavest, plurivest sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4154,Biovance 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4155,Neoxflo or clarixflo 1 mg,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4156,Neox 100 or clarix 100,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4157,Revitalon 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4158,"Kerecis omega3, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4159,Affinity1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4160,Nushield 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4161,Bio-connekt per square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4162,"Wndex flw, bioskn flw, 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4163,"Woundex, bioskin, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4164,"Helicoll, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4165,"Keramatrix, kerasorb sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4166,"Cytal, per square centimeter",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4167,"Truskin, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4168,"Amnioband, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4169,"Artacent wound, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4170,"Cygnus, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4171,"Interfyl, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4172,Puraply or puraply am,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4173,Palingen or palingen xplus,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4174,Palingen or promatrx,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4175,Miroderm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4176,"Neopatch or therion, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4177,"Floweramnioflo, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4178,"Floweramniopatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4179,"Flowerderm, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4180,"Revita, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4181,"Amnio wound, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4182,"Transcyte, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4183,"Surgigraft, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4184,Cellesta or duo per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4185,Cellesta flowab amnion 0.5cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4186,Epifix 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4187,Epicord 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4188,Amnioarmor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4189,"Artacent ac, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4190,Artacent ac 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4191,Restorigin 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4192,"Restorigin, 1 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4193,Coll-e-derm 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4194,Novachor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4195,Puraply 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4196,Puraply am 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4197,Puraply xt 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4198,Genesis amnio membrane 1sqcm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4200,Skin te 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4201,Matrion 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4202,"Keroxx (2.5g/cc), 1cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4203,"Derma-gide, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4204,Xwrap 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4205,Membrane graft or wrap sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4206,Fluid flow or fluid gf 1 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4208,Novafix per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4209,Surgraft per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4210,Axolotl graf dualgraf sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4211,Amnion bio or axobio sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4212,"Allogen, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4213,"Ascent, 0.5 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4214,Cellesta cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4215,"Axolotl ambient, cryo 0.1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4216,Artacent cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4217,Woundfix biowound plus xplus,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4218,Surgicord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4219,Surgigraft dual per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4220,"Bellacell hd, surederm sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4221,Amniowrap2 per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4222,"Progenamatrix, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4226,Myown harv prep proc sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4227,Amniocore per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4228,"Bionextpatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4229,Cogenex amnio memb per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4230,Cogenex flow amnion 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4231,"Corplex p, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4232,"Corplex, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4233,Surfactor /nudyn per 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4234,"Xcellerate, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4235,Amniorepair or altiply sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4236,Carepatch per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4237,"Cryo-cord, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4238,"Derm-maxx, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4239,Amnio-maxx or lite per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4240,Corecyte topical only 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4241,"Polycyte, topical only 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4242,"Amniocyte plus, per 0.5 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4244,"Procenta, per 200 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4245,"Amniotext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4246,"Coretext or protext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4247,"Amniotext patch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4248,Dermacyte amn mem allo sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4249,"Amniply, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4250,Amnioamp-mp per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4254,Novafix dl per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q4255,"Reguard, topical use per sq",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q5101,"Injection, zarxio",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q5102,"Inj., infliximab biosimilar",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5103,"Injection, inflectra",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5104,"Injection, renflexis",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5105,Inj retacrit esrd on dialysi,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q5106,Inj retacrit non-esrd use,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q5107,Inj mvasi 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q5108,"Injection, fulphila",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5109,"Injection, ixifi, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q5110,Nivestym,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q5111,"Injection, udenyca 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5112,Inj ontruzant 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5113,Inj herzuma 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5114,Inj ogivri 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5115,Inj truxima 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5116,"Inj., trazimera, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5117,"Inj., kanjinti, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5118,"Inj., zirabev, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q5119,"Inj ruxience, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5121,"Inj. avsola, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q5122,"Inj, nyvepria",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q9975,Factor VIII FC Fusion Recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Meridian Medicaid,CPT,Q9979,"Injection, Alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q9980,"Genvisc, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q9984,Kyleena,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q9987,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q9988,Platelet pheresis path reduc,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q9989,"Ustekinumab IV Inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q9991,Buprenorph xr 100 mg or less,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q9992,Buprenorphine xr over 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q9993,"Inj., triamcinolone ext rel",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,Q9995,"inj. emicizumab-kxwh, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S0013,"Esketamine, nasal spray",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0040,"Injection, ticarcillin disod",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0088,Imatinib 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0126,Inj follitropin alfa 75 iu,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0132,Inj ganirelix acetat 250 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0140,"Saquinavir, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0142,Colistimethate inh sol mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0145,Peg interferon alfa-2a/180,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0148,Peg interferon alfa-2b/10,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0155,Epoprostenol dilutant,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0166,Inj olanzapine 2.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0175,Flutamide 125 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0178,Lomustine 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0190,"Mifepristone, oral, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0195,Pneumo vaccine 5-9 yrs,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0199,Med abortion inc all ex drug,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0201,Partial hospitalization serv,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0220,Medical conference by physic,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0221,"Medical conference, 60 min",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0250,Comp geriatr assmt team,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0257,End of life counseling,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0271,Home hospice case 30 days,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0280,"Medical home, initial plan",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0281,"Medical home, maintenance",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0311,Comp mgmt care coord adv ill,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0315,Disease management program,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0316,Follow-up/reassessment,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0340,Lifestyle mod 1st stage,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0353,Cancer treatmentplan initial,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0354,Cancer treatment plan change,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0390,Rout foot care per visit,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0395,Impression casting ft,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0592,Comp cont lens eval,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0601,Screening proctoscopy,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0618,Audiometry for hearing aid,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0800,Laser in situ keratomileusis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S0810,Photorefractive keratectomy,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S0812,Phototherap keratect,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2066,Breast gap flap reconst,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2067,"Breast ""stacked"" diep/gap",General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2068,Breast diep or siea flap,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2083,Adjustment gastric band,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2112,Knee arthroscp harv,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2202,Echosclerotherapy,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2225,Myringotomy laser-assist,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2230,Implant semi-imp hear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2235,Implant auditory brain imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2260,Induced abortion 17-24 weeks,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2265,Induced abortion 25-28 wks,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2266,Induced abortion 29-31 wks,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2267,Induced abortion 32 or more,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2300,"Arthroscopy, shoulder, surgi",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2340,Chemodenervation of abductor,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2341,Chemodenerv adduct vocal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Meridian Medicaid,CPT,S2342,Nasal endoscop po debrid,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2400,Fetal surg congen hernia,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2401,Fetal surg urin trac obstr,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2402,Fetal surg cong cyst malf,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2403,Fetal surg pulmon sequest,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2404,Fetal surg myelomeningo,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2405,Fetal surg sacrococ teratoma,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2409,Fetal surg noc,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S2411,Fetoscop laser ther ttts,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3620,Newborn metabolic screening,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3630,Eosinophil blood count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3645,Hiv-1 antibody testing of or,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3650,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3652,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3655,Antisperm antibodies test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3708,Gastrointestinal fat absorpt,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3721,Pca3 testing,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3722,Dose optimization auc - 5fu,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3800,Genetic testing als,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3840,Dna analysis ret-oncogene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3841,Gene test retinoblastoma,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3842,Gene test hippel-lindau,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3844,Dna analysis deafness,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3845,Gene test alpha-thalassemia,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3846,Gene test beta-thalassemia,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3849,Gene test niemann-pick,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3850,Gene test sickle cell,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3852,Dna analysis apoe alzheimer,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3853,Gene test myo musclr dyst,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3854,Gene profile panel breast,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3861,Genetic test brugada,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3865,Comp genet test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3866,Spec gene test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3870,Cgh test developmental delay,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3890,Fecal dna analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3900,Surface emg,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3902,Ballistocardiogram,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S3904,Masters two step,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4011,Ivf package,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4013,Compl gift case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4014,Compl zift case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4015,Complete ivf nos case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4016,Frozen ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4017,Ivf canc a stim case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4018,F emb trns canc case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4020,Ivf canc a aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4021,Ivf canc p aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4022,Asst oocyte fert case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4023,Incompl donor egg case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4025,Donor serv ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4026,Procure donor sperm,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4027,Store prev froz embryos,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4028,Microsurg epi sperm asp,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4030,Sperm procure init visit,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4031,Sperm procure subs visit,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4035,Stimulated iui case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4037,Cryo embryo transf case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4040,Monit store cryo embryo 30 d,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4042,Ovulation mgmt per cycle,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4981,Insert levonorgestrel ius,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S4989,Contracept iud,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S5180,Hh respiratory thrpy in eval,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S5181,Hh respiratory thrpy nos/day,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8032,Low dose CT lung screening,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8035,Magnetic source imaging,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8037,Mrcp,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8055,Us guidance fetal reduct,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8080,Scintimammography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8092,Electron beam computed tomog,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8110,Peak expiratory flow rate (p,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8930,Auricular electrostimulation,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8940,Hippotherapy per session,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8948,Low-level laser trmt 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8950,"Complex lymphedema therapy,",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S8990,Pt or manip for maint,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9015,Automated eeg monitoring,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9024,Paranasal sinus ultrasound,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9061,Medical supplies and equipme,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9090,Vertebral axial decompressio,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9098,Home phototherapy visit,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9128,"Speech therapy, in the home,",Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9129,"Occupational therapy, in the",Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9131,Pt in the home per diem,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9140,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9141,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9145,Insulin pump initiation,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9152,"Speech therapy, re-eval",Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9211,Home mgmt gest hypertension,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9213,Hm preeclamp per diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9214,Hm gest dm per diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9335,Ht hemodialysis diem,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9339,Hit periton dialysis diem,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9370,Ht inj antiemetic diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9372,Ht inj anticoag diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9445,Pt education noc individ,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9446,Pt education noc group,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9452,Nutrition class,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9453,Smoking cessation class,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9455,"Diabetic management program,",Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9465,"Diabetic management program,",Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9470,"Nutritional counseling, diet",Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9472,Cardiac rehabilitation progr,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9473,Pulmonary rehabilitation pro,Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9475,Ambulatory setting substance,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9476,Vestibular rehab per diem,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9480,Intensive outpatient psychia,Behavioral Health,Per Unit,$339.88 ,OP,$339.88 ,$339.88 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9482,Family stabilization 15 min,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9484,Crisis intervention per hour,Behavioral Health,Per Unit,$135.70 ,OP,$135.70 ,$135.70 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9485,Crisis intervention mental h,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9537,Ht hem horm inj diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9538,Hit blood products diem,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9558,Ht inj growth horm diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9559,Hit inj interferon diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9560,Ht inj hormone diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,S9562,Ht inj palivizumab diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,T1006,Family/couple counseling,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Meridian Medicaid,CPT,T1007,Treatment plan development,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Meridian Medicaid,CPT,T1012,Alcohol/substance abuse skil,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Meridian Medicaid,CPT,T1016,Case management,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,T1017,Targeted case management,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,T1023,Program intake assessment,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Meridian Medicaid,CPT,T1040,Comm bh clinic svc per diem,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Meridian Medicaid,CPT,T2022,"Case management, per month",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,T2023,Targeted case mgmt per month,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Meridian Medicaid,CPT,U0001,2019-ncov diagnostic p,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Meridian Medicaid,CPT,U0002,Covid-19 lab test non-cdc,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,U0005,Infec agen detec ampli probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Meridian Medicaid,CPT,V2785,Corneal tissue processing,Ophthalmology,Per Unit,"$1,390.89 ",OP,"$1,390.89 ","$1,390.89 ",,,,,,,,,,,,
Meridian Medicaid,CPT,V2790,Amniotic membrane,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Meridian Medicaid,CPT,V5362,Speech screening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,V5363,Language screening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Meridian Medicaid,CPT,V5364,Dysphagia screening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","463,441.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","254,896.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","303,857.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","189,792.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","163,572.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","75,067.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-007,LUNG TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","185,188.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,828.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-010,PANCREAS TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,883.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,262.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,310.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-013,TRACHEOSTOMY FOR FACE - MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,528.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","204,460.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","107,619.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,283.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","597,264.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","106,590.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","165,121.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","120,505.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,753.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,596.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,920.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","71,867.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,928.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,188.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","93,120.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,720.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,713.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,857.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,395.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,531.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,593.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,393.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,619.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,395.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,516.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,224.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,324.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,617.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,158.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,521.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,177.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,852.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,694.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,996.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,227.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,787.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,024.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,649.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-061,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,211.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-062,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,795.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,358.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,608.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,291.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,374.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,793.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,217.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,577.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,822.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,172.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,339.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,190.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,294.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,016.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,694.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,510.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,184.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,628.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,472.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,352.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,129.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,467.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,467.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,902.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,366.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,801.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-088,CONCUSSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,348.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-089,CONCUSSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,979.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,676.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,382.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,777.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,500.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,129.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,128.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,304.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,041.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,774.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,356.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-100,SEIZURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,977.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-101,SEIZURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,192.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-102,HEADACHES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,427.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-103,HEADACHES W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,251.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,068.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,128.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,252.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,035.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,622.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,019.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,300.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,244.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,380.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,366.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,249.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,088.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,497.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,489.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-139,SALIVARY GLAND PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,628.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,689.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,320.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,740.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,420.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,008.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-145,OTHER EAR - NOSE - MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,416.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,529.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,817.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,580.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-149,DYSEQUILIBRIUM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,768.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-150,EPISTAXIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,195.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-151,EPISTAXIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,792.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,230.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,369.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,680.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,508.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-156,OTHER EAR - NOSE - MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,521.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,158.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,225.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,492.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","79,377.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,227.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,617.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,660.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,790.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,905.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,707.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,187.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,524.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,294.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,937.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,804.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,934.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,600.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,889.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,630.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,377.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,691.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-187,PLEURAL EFFUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,515.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,649.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,596.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,982.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,129.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,118.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,971.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,808.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,640.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,777.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,089.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,876.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-199,PNEUMOTHORAX WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,601.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-200,PNEUMOTHORAX WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,200.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,352.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,449.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,288.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,680.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,916.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,147.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,622.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,676.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","178,526.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","166,881.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","103,884.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,291.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","128,881.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,398.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,836.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","134,737.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","99,393.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","117,795.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,028.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","105,788.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","84,030.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","99,444.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,808.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","135,843.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","94,372.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","124,683.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,078.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","96,483.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","65,292.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","76,939.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,638.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,462.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,560.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,521.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,051.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-245,AICD GENERATOR PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,624.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,011.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,811.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,782.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,068.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,364.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,556.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,131.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,459.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,952.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,688.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,289.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,576.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,220.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,923.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,347.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,860.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,329.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-263,VEIN LIGATION AND STRIPPING,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,884.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,964.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-265,AICD LEAD PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,803.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","113,555.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","89,614.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","111,273.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,033.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,905.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,033.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,020.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,395.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,566.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,019.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,913.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,608.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,833.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,747.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","7,942.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,425.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI - WITH CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,400.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,896.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,281.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,377.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,454.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,321.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,441.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,513.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,700.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,516.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,273.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","7,811.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,502.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,675.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,880.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,496.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,822.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-304,HYPERTENSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,529.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-305,HYPERTENSION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,816.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,059.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,894.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,188.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,990.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,934.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-311,ANGINA PECTORIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,152.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-312,SYNCOPE AND COLLAPSE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,395.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-313,CHEST PAIN,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,532.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,334.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,603.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,992.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,052.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,099.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,043.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","41,753.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,648.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,604.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,624.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,361.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-332,RECTAL RESECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","66,555.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-333,RECTAL RESECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,256.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,747.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,246.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,526.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,121.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,780.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,120.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,654.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,059.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,929.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,750.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,814.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,243.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,400.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,385.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,478.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,668.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,238.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,846.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,648.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,132.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,528.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,747.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,662.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,059.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,424.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,076.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,228.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,961.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,652.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,441.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,896.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,086.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,278.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,323.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,782.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,891.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,193.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,129.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,955.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,292.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,974.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,278.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,905.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,896.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,416.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,188.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,148.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,321.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,910.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,230.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,457.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,017.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,395.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,688.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-406,PANCREAS - LIVER AND SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,032.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-407,PANCREAS - LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,856.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,992.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,828.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,051.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,038.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,411.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,702.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,008.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,510.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,755.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,776.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,009.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,043.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","56,225.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,542.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,222.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","66,864.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,505.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,692.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,113.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,456.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,913.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,044.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,923.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,312.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,540.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,510.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,694.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,139.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,905.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,604.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,700.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,228.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,059.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","147,097.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","97,569.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","76,656.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","137,569.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","104,032.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,278.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","107,708.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,923.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","97,219.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,307.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,846.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,592.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,497.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,520.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,219.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,864.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","49,350.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,398.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,268.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,851.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,643.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","65,164.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,097.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,556.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,710.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,710.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,948.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,392.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,528.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,348.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,180.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","54,521.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,374.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,244.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,593.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,771.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","55,491.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,203.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,630.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,147.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,769.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,339.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","41,348.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,179.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,462.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,920.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,292.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-503,FOOT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,059.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-504,FOOT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,382.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,382.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,611.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,356.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,624.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-509,ARTHROSCOPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,780.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,691.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,496.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,899.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,944.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-514,HAND OR WRIST PROCEDURES - EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,907.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,192.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,377.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,347.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,348.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,323.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,678.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","49,014.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,025.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,601.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,617.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,740.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,345.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,931.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,542.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-539,OSTEOMYELITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,059.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-540,OSTEOMYELITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,724.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,449.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,884.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,692.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,419.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,992.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,305.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,328.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,473.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-549,SEPTIC ARTHRITIS W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,950.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,123.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,969.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,072.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,292.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,646.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,804.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,900.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-557,TENDONITIS - MYOSITIS AND BURSITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,302.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,732.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,886.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,222.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,657.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,528.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,932.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,220.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,100.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,024.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","45,380.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,124.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,641.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","88,596.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,944.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,184.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,961.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,758.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,515.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,844.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,649.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,158.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,265.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,665.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,284.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,876.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-592,SKIN ULCERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,987.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-593,SKIN ULCERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,188.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,099.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,193.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,827.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,187.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,779.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,739.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,931.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,001.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-602,CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,985.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-603,CELLULITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,516.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-604,TRAUMA TO THE SKIN - SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,860.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,547.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,176.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,209.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,188.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,185.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,820.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,545.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,848.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,977.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,177.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,542.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,804.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE - NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,966.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,508.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","45,459.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-626,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,436.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-627,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,908.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,169.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,548.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,510.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-637,DIABETES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,995.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-638,DIABETES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,070.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-639,DIABETES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,748.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,644.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,048.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,600.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,612.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,292.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,284.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,209.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,097.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-652,KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,910.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","87,187.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,403.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,281.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,507.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,945.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,265.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,636.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,094.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,030.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,876.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,518.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,947.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-665,PROSTATECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,587.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-666,PROSTATECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,748.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,918.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,081.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,510.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,624.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,427.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,414.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","55,409.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,086.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,032.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-682,RENAL FAILURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,523.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-683,RENAL FAILURE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,049.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,720.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,971.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,764.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,964.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,780.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,675.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-693,URINARY STONES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,300.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-694,URINARY STONES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,668.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,180.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,035.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-697,URETHRAL STRICTURE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,952.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,707.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,403.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,916.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,729.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,862.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,990.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,598.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,084.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,920.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,865.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,856.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,302.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,424.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,776.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,779.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,344.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,425.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,390.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,510.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,892.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,689.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,856.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,076.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,051.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-734,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,564.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-735,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,616.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,131.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,931.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,625.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,147.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,800.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,472.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,472.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,116.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,704.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,728.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-746,VAGINA - CERVIX AND VULVA PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,750.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,008.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,572.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,318.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,454.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,136.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,041.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,657.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,353.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,472.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,931.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,761.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,440.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,732.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,926.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,209.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,300.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-779,ABORTION WITHOUT D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,646.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,963.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,518.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,644.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,457.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,003.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,193.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Acute Care,Per Diem,"$5,358.42 ",IP,600,"27,496.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Acute Care,Per Diem,"$5,358.42 ",IP,600,"90,673.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"61,926.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"37,364.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"63,611.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"22,515.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-795,NORMAL NEWBORN,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,086.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,718.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,236.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-799,SPLENECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,302.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-800,SPLENECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,222.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,936.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,339.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,156.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,827.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,428.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,742.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,257.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,846.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,547.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,371.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,041.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,075.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-813,COAGULATION DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,715.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,251.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,880.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,574.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,828.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,064.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,966.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,996.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,481.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,025.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","71,953.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,803.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,411.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,588.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,961.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,843.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,291.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,624.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,937.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,476.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,576.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","96,801.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,819.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,713.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,185.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,140.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,780.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,451.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,932.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,524.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,446.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,888.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,558.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,718.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,363.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,464.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-849,RADIOTHERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,800.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","79,113.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,510.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,920.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,731.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,555.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,574.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,060.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,638.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,000.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-865,VIRAL ILLNESS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,662.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,395.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,672.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,934.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,616.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","102,796.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,891.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,345.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,180.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Acute Care,Per Diem,"$5,358.42 ",IP,550,"13,817.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-881,DEPRESSIVE NEUROSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"12,822.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Acute Care,Per Diem,"$5,358.42 ",IP,550,"13,168.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Acute Care,Per Diem,"$5,358.42 ",IP,550,"25,252.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Acute Care,Per Diem,"$5,358.42 ",IP,550,"23,100.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-885,PSYCHOSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"19,793.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,550,"19,544.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"17,259.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,760.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,472.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-896,ALCOHOL - DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,432.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,208.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,195.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,398.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,150.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,542.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,345.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,700.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,313.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,646.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,993.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,182.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,217.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,161.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,516.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,640.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,657.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,350.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,436.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,062.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,401.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,886.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","336,494.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","104,419.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,142.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,121.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,044.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-935,NON-EXTENSIVE BURNS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,932.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","54,179.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,481.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,795.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-945,REHABILITATION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,755.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,035.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,041.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,569.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-949,AFTERCARE WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,713.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,822.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,931.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","100,608.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,580.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","118,732.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","67,286.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,747.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,587.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,814.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,606.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","92,598.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,121.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,971.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,465.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,185.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,132.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","73,724.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,659.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,476.80",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,193.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,891.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,854.40",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
Molina Healthcare of IL Duals,DRG,MS-999,UNGROUPABLE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
Molina Healthcare of IL Duals,ExceptPatType,14,,Swing Bed,Per Diem,"$4,816.25 ",IP,640,"4,816.25",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,94.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,8.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,7.01,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,47.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,8.68,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,47.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,16.38,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,13.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,16.59,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,60,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,16.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,16.13,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,11.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,12.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,17.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,32.62,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,86.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,78.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,125.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,80.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,801.62,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,51.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,55.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,209.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,43.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,579.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,161.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,46.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,50.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,148.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,66.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,129.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,165.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,285.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,103,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,91.16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,50.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,67.21,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,4.02,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,3.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,3.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,2.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,2.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,4.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,3.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,260.5,260.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,897,897,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,68.92,68.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,54.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,"1,487.37","1,487.37",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,55.54,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,153.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,69.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,16.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,38.62,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,25.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,7.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,6.23,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,30,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,40.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,16.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,25.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,13.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,22.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,19.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,9.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,6.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,25.55,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,20.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,21.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,18.97,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,15.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,16.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,17.12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,26.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,4.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,4.38,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,5.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,15.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,23.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,26.79,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,13.68,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,6.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,4.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,12.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,14.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,18.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,9.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,27.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,29.08,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,25.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,14.12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,12.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,4.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,4.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,7.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,20.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,20.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,27.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,18.68,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,12.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,22.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,16.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,4.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,24.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,6.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,11.55,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,11.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,5.12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,9.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,25.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,22.23,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,38.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,22.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,61.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,18.79,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,32.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,21.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,24.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,24.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,14.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,26.24,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,22.97,22.97,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,19.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,13.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,18.54,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,14.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,17.34,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,11.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,21.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,9.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,16.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,8.02,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,78.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,17.69,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,17.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,14.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,17.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,5.04,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,3.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,9.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,13.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,15.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,16.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,18.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,16.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,12.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,26.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,7.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,20.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,21.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,6.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,8.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,29.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,17.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,22.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,27.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,22.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,24.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,18.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,11.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,19.82,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,8.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,8.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,12.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,6.04,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,12.79,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,19.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,20.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,11.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,19.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,46.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,12.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,10.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,6.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,26.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,16.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,17.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,12.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,13.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,24.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,27.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,23.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,21.21,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,29.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,14.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,41.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,3.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,7.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,8.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,16.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,10.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,4.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,8.44,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,14.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,4.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,4.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,14.59,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,21.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,21.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,20.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,22.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,20.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,19.38,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,5.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,17.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,29.21,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,14.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,26.69,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,28.1,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,14.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,87.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,64.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,71.23,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,36.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,25.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,21.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,25.21,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,4.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,5.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,4.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,21.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,18.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,8.1,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,5.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,25.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,21.23,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,16.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,6.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,9.02,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,5.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,12.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,15.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,12.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,9.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,10.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,10.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,5.13,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,5.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,5.08,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,4.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,17.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,13.72,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,17.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,12.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,11.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,12.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,4.82,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,3.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,5.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,3.02,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,2.54,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,4.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,35.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,11.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,20.37,20.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,12.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,20.42,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,19.04,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,9.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,11.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,10.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,13.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,4.28,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,4.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,80.46,80.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,12.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,15.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,4.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,9.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,8.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,11.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,6.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,18.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,24.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,4.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,3.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,9.58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,9.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,2.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,5.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,6.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,9.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,11.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,7.82,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,5.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,18.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,11.16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,8.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,20.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,10.01,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,25.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,14.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,23.13,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,24.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,22.34,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,29.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,15.59,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,21.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,23.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,10.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,49.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,46.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,77.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,14.55,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,16.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,11.54,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,10.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,6.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,5.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,61.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,4.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,13.38,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,11.82,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,12.68,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,11.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,12.12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,15.21,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,13.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,18.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,14.16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,13.01,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,9.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,17.16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,13.79,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,8.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,13.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,13.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,11.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,13.55,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,16.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,15.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,18.23,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,24.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,14.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,15.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,14.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,189.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,47.59,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,78.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,29.68,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,106.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,36.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,8.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,16.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,6.68,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,8.62,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,6.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,27.07,27.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,8.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,20.46,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,15.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,19.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,10.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,14.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,11.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,8.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,7.48,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,40.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,15.02,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,5.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,19.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,20.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,15.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,16.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,60.8,60.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,12.18,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,16.1,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,13.82,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,14.38,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,21.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,14.13,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,13.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,16.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,10.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,55.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,22.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,53.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,31.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,29.8,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,85.1,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,58.62,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,48.24,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,41.68,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,27.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,302.62,302.62,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,40.55,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,43.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,12.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,16.55,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,32.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,13.1,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,21.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,35.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,24.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,16.53,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,130.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,12.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,7.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,23.04,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,50.56,50.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,27.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,24.03,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,14.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,42.22,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,25.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,26.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,116.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,140.73,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,150.3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,143.75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,147.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,13.07,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,264.34,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,125.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,150.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,144.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,188.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,173.66,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,21.42,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,40.7,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,34.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,42.38,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,51.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,33.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,26.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,34.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,4.72,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,5.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,7.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,4.85,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,5.79,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,9.84,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,12.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,10.38,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,6.5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,19.31,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,27.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,43.97,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,26.49,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,31.94,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,5.83,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
Molina Healthcare of IL Duals,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
Molina Healthcare of IL Duals,,,,All Other,Straight Discount,30.00%,OP,,,,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,11,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$38,043.18 ",IP,"38,043.18","38,043.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,12,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$40,281.56 ",IP,"40,281.56","40,281.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,13,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$42,053.29 ",IP,"42,053.29","42,053.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,14,LIVER TRANSPLANT andOR INTESTINAL TRANSPLANT,,Relative Weights,"$78,175.26 ",IP,"78,175.26","78,175.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,21,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$45,599.51 ",IP,"45,599.51","45,599.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,22,HEART &/OR LUNG TRANSPLANT,,Relative Weights,"$58,026.75 ",IP,"58,026.75","58,026.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,23,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$74,400.53 ",IP,"74,400.53","74,400.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,24,HEART andOR LUNG TRANSPLANT,,Relative Weights,"$107,953.54 ",IP,"107,953.54","107,953.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,41,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$33,014.21 ",IP,"33,014.21","33,014.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,42,TRACHEOSTOMY W MV 96+ HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$37,820.51 ",IP,"37,820.51","37,820.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,43,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$49,052.96 ",IP,"49,052.96","49,052.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,44,TRACHEOSTOMY W MV 96 HOURS W EXTENSIVE PROCEDURE,,Relative Weights,"$72,921.22 ",IP,"72,921.22","72,921.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,51,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$23,684.08 ",IP,"23,684.08","23,684.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,52,TRACHEOSTOMY W MV 96+ HOURS W/O EXTENSIVE PROCEDURE,,Relative Weights,"$26,315.91 ",IP,"26,315.91","26,315.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,53,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$36,197.91 ",IP,"36,197.91","36,197.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,54,TRACHEOSTOMY W MV 96 HOURS WO EXTENSIVE PROCEDURE,,Relative Weights,"$48,934.75 ",IP,"48,934.75","48,934.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,61,PANCREAS TRANSPLANT,,Relative Weights,"$40,520.03 ",IP,"40,520.03","40,520.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,62,PANCREAS TRANSPLANT,,Relative Weights,"$45,022.22 ",IP,"45,022.22","45,022.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,63,PANCREAS TRANSPLANT,,Relative Weights,"$47,794.94 ",IP,"47,794.94","47,794.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,64,PANCREAS TRANSPLANT,,Relative Weights,"$66,459.33 ",IP,"66,459.33","66,459.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,71,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$38,434.91 ",IP,"38,434.91","38,434.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,72,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$48,059.19 ",IP,"48,059.19","48,059.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,73,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$59,827.69 ",IP,"59,827.69","59,827.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,74,ALLOGENEIC BONE MARROW TRANSPLANT,,Relative Weights,"$99,672.84 ",IP,"99,672.84","99,672.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,81,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$22,091.37 ",IP,"22,091.37","22,091.37",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,82,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$27,118.96 ",IP,"27,118.96","27,118.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,83,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$32,175.76 ",IP,"32,175.76","32,175.76",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,84,AUTOLOGOUS BONE MARROW TRANSPLANT,,Relative Weights,"$51,576.54 ",IP,"51,576.54","51,576.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,91,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$27,699.69 ",IP,"27,699.69","27,699.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,92,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$30,776.86 ",IP,"30,776.86","30,776.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,93,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$36,358.72 ",IP,"36,358.72","36,358.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,94,EXTRACORPOREAL MEMBRANE OXYGENATION (ECMO),,Relative Weights,"$79,300.63 ",IP,"79,300.63","79,300.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,101,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$4,104.27 ",IP,"4,104.27","4,104.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,102,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,103,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$12,592.86 ",IP,"12,592.86","12,592.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,104,HEAD TRAUMA WITH DEEP COMA,,Relative Weights,"$37,584.09 ",IP,"37,584.09","37,584.09",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,201,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$9,991.61 ",IP,"9,991.61","9,991.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,202,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$11,868.15 ",IP,"11,868.15","11,868.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,203,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$16,002.32 ",IP,"16,002.32","16,002.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,204,CRANIOTOMY FOR TRAUMA,,Relative Weights,"$28,673.87 ",IP,"28,673.87","28,673.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,211,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$9,882.68 ",IP,"9,882.68","9,882.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,212,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$13,243.69 ",IP,"13,243.69","13,243.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,213,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$18,834.48 ",IP,"18,834.48","18,834.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,214,CRANIOTOMY EXCEPT FOR TRAUMA,,Relative Weights,"$27,671.86 ",IP,"27,671.86","27,671.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,221,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$6,449.86 ",IP,"6,449.86","6,449.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,222,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$7,492.76 ",IP,"7,492.76","7,492.76",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,223,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$10,628.01 ",IP,"10,628.01","10,628.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,224,VENTRICULAR SHUNT PROCEDURES,,Relative Weights,"$25,450.32 ",IP,"25,450.32","25,450.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,231,SPINAL PROCEDURES,,Relative Weights,"$7,646.71 ",IP,"7,646.71","7,646.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,232,SPINAL PROCEDURES,,Relative Weights,"$9,630.12 ",IP,"9,630.12","9,630.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,233,SPINAL PROCEDURES,,Relative Weights,"$16,000.26 ",IP,"16,000.26","16,000.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,234,SPINAL PROCEDURES,,Relative Weights,"$29,075.91 ",IP,"29,075.91","29,075.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,241,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$5,741.65 ",IP,"5,741.65","5,741.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,242,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$6,726.14 ",IP,"6,726.14","6,726.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,243,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$13,747.79 ",IP,"13,747.79","13,747.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,244,EXTRACRANIAL VASCULAR PROCEDURES,,Relative Weights,"$24,782.31 ",IP,"24,782.31","24,782.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,261,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,157.39 ",IP,"7,157.39","7,157.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,262,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$8,935.31 ",IP,"8,935.31","8,935.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,263,OTHER NERVOUS SYSTEM and RELATED PROCEDURES,,Relative Weights,"$12,455.76 ",IP,"12,455.76","12,455.76",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,264,OTHER NERVOUS SYSTEM & RELATED PROCEDURES,,Relative Weights,"$22,781.03 ",IP,"22,781.03","22,781.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,401,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,482.55 ",IP,"5,482.55","5,482.55",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,402,SPINAL DISORDERS and INJURIES,,Relative Weights,"$5,877.72 ",IP,"5,877.72","5,877.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,403,SPINAL DISORDERS and INJURIES,,Relative Weights,"$8,545.98 ",IP,"8,545.98","8,545.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,404,SPINAL DISORDERS and INJURIES,,Relative Weights,"$17,945.87 ",IP,"17,945.87","17,945.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,411,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,340.00 ",IP,"4,340.00","4,340.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,412,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$4,441.02 ",IP,"4,441.02","4,441.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,413,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$5,802.81 ",IP,"5,802.81","5,802.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,414,NERVOUS SYSTEM MALIGNANCY,,Relative Weights,"$8,029.51 ",IP,"8,029.51","8,029.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,421,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,328.02 ",IP,"3,328.02","3,328.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,422,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$3,814.25 ",IP,"3,814.25","3,814.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,423,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$5,381.53 ",IP,"5,381.53","5,381.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,424,DEGENERATIVE NERVOUS SYSTEM DISORDERS EXC MULT SCLEROSIS,,Relative Weights,"$12,544.07 ",IP,"12,544.07","12,544.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,431,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$4,040.70 ",IP,"4,040.70","4,040.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,432,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$5,014.88 ",IP,"5,014.88","5,014.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,433,MULTIPLE SCLEROSIS and OTHER DEMYELINATING DISEASES,,Relative Weights,"$7,268.72 ",IP,"7,268.72","7,268.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,434,MULTIPLE SCLEROSIS & OTHER DEMYELINATING DISEASES,,Relative Weights,"$15,032.61 ",IP,"15,032.61","15,032.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,441,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$3,968.19 ",IP,"3,968.19","3,968.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,442,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$4,927.25 ",IP,"4,927.25","4,927.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,443,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$6,702.77 ",IP,"6,702.77","6,702.77",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,444,INTRACRANIAL HEMORRHAGE,,Relative Weights,"$9,326.01 ",IP,"9,326.01","9,326.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,451,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$3,612.20 ",IP,"3,612.20","3,612.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,452,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$4,429.34 ",IP,"4,429.34","4,429.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,453,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$5,951.60 ",IP,"5,951.60","5,951.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,454,CVA and PRECEREBRAL OCCLUSION W INFARCT,,Relative Weights,"$10,976.10 ",IP,"10,976.10","10,976.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,461,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$3,784.70 ",IP,"3,784.70","3,784.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,462,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$4,264.40 ",IP,"4,264.40","4,264.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,463,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$5,292.53 ",IP,"5,292.53","5,292.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,464,NONSPECIFIC CVA and PRECEREBRAL OCCLUSION WO INFARCT,,Relative Weights,"$10,621.82 ",IP,"10,621.82","10,621.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,471,TRANSIENT ISCHEMIA,,Relative Weights,"$3,321.15 ",IP,"3,321.15","3,321.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,472,TRANSIENT ISCHEMIA,,Relative Weights,"$3,597.42 ",IP,"3,597.42","3,597.42",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,473,TRANSIENT ISCHEMIA,,Relative Weights,"$4,242.41 ",IP,"4,242.41","4,242.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,474,TRANSIENT ISCHEMIA,,Relative Weights,"$7,719.21 ",IP,"7,719.21","7,719.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,481,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,400.87 ",IP,"3,400.87","3,400.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,482,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$3,627.32 ",IP,"3,627.32","3,627.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,483,PERIPHERAL CRANIAL and AUTONOMIC NERVE DISORDERS,,Relative Weights,"$4,545.48 ",IP,"4,545.48","4,545.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,484,"PERIPHERAL, CRANIAL & AUTONOMIC NERVE DISORDERS",,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,491,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$5,943.01 ",IP,"5,943.01","5,943.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,492,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$9,716.03 ",IP,"9,716.03","9,716.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,493,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$11,066.13 ",IP,"11,066.13","11,066.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,494,BACTERIAL and TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM,,Relative Weights,"$20,732.33 ",IP,"20,732.33","20,732.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,501,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$3,211.53 ",IP,"3,211.53","3,211.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,502,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$6,688.34 ",IP,"6,688.34","6,688.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,503,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$10,165.49 ",IP,"10,165.49","10,165.49",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,504,NONBACTERIAL INFECTIONS OF NERVOUS SYSTEM EXC VIRAL MENINGITIS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,511,VIRAL MENINGITIS,,Relative Weights,"$2,048.35 ",IP,"2,048.35","2,048.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,512,VIRAL MENINGITIS,,Relative Weights,"$3,205.00 ",IP,"3,205.00","3,205.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,513,VIRAL MENINGITIS,,Relative Weights,"$5,993.52 ",IP,"5,993.52","5,993.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,514,VIRAL MENINGITIS,,Relative Weights,"$12,441.32 ",IP,"12,441.32","12,441.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,521,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,101.91 ",IP,"3,101.91","3,101.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,522,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$3,492.61 ",IP,"3,492.61","3,492.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,523,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$4,423.15 ",IP,"4,423.15","4,423.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,524,ALTERATION IN CONSCIOUSNESS,,Relative Weights,"$9,303.33 ",IP,"9,303.33","9,303.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,531,SEIZURE,,Relative Weights,"$2,710.87 ",IP,"2,710.87","2,710.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,532,SEIZURE,,Relative Weights,"$3,311.87 ",IP,"3,311.87","3,311.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,533,SEIZURE,,Relative Weights,"$4,410.44 ",IP,"4,410.44","4,410.44",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,534,SEIZURE,,Relative Weights,"$10,918.03 ",IP,"10,918.03","10,918.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,541,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$2,681.66 ",IP,"2,681.66","2,681.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,542,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,180.26 ",IP,"3,180.26","3,180.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,543,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,544,MIGRAINE and OTHER HEADACHES,,Relative Weights,"$6,681.46 ",IP,"6,681.46","6,681.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,551,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$3,376.47 ",IP,"3,376.47","3,376.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,552,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$4,570.57 ",IP,"4,570.57","4,570.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,553,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$6,561.54 ",IP,"6,561.54","6,561.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,554,HEAD TRAUMA W COMA 1 HR OR HEMORRHAGE,,Relative Weights,"$13,008.65 ",IP,"13,008.65","13,008.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,561,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$3,264.10 ",IP,"3,264.10","3,264.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,562,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$4,370.58 ",IP,"4,370.58","4,370.58",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,563,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$6,249.87 ",IP,"6,249.87","6,249.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,564,BRAIN CONTUSIONLACERATION and COMPLICATED SKULL FX COMA 1 HR OR NO COMA,,Relative Weights,"$13,974.93 ",IP,"13,974.93","13,974.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,571,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,572,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$3,996.71 ",IP,"3,996.71","3,996.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,573,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$5,550.25 ",IP,"5,550.25","5,550.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,574,CONCUSSION CLOSED SKULL FX NOSUNCOMPLICATED INTRACRANIAL INJURY COMA 1 HR OR NO COMA,,Relative Weights,"$10,437.98 ",IP,"10,437.98","10,437.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,581,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$3,385.75 ",IP,"3,385.75","3,385.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,582,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$4,062.35 ",IP,"4,062.35","4,062.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,583,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$5,313.15 ",IP,"5,313.15","5,313.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,584,OTHER DISORDERS OF NERVOUS SYSTEM,,Relative Weights,"$10,386.78 ",IP,"10,386.78","10,386.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,591,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$3,746.90 ",IP,"3,746.90","3,746.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,592,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$4,463.01 ",IP,"4,463.01","4,463.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,593,ANOXIC and OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$6,809.98 ",IP,"6,809.98","6,809.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,594,ANOXIC & OTHER SEVERE BRAIN DAMAGE,,Relative Weights,"$11,699.43 ",IP,"11,699.43","11,699.43",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,731,ORBIT AND EYE PROCEDURES,,Relative Weights,"$5,014.53 ",IP,"5,014.53","5,014.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,732,ORBIT AND EYE PROCEDURES,,Relative Weights,"$6,421.34 ",IP,"6,421.34","6,421.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,733,ORBIT AND EYE PROCEDURES,,Relative Weights,"$9,718.43 ",IP,"9,718.43","9,718.43",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,734,ORBIT AND EYE PROCEDURES,,Relative Weights,"$22,403.73 ",IP,"22,403.73","22,403.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,821,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$2,633.21 ",IP,"2,633.21","2,633.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,822,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$3,410.83 ",IP,"3,410.83","3,410.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,823,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$4,809.73 ",IP,"4,809.73","4,809.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,824,EYE INFECTIONS AND OTHER EYE DISORDERS,,Relative Weights,"$13,027.89 ",IP,"13,027.89","13,027.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,891,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$9,059.01 ",IP,"9,059.01","9,059.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,892,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$11,457.52 ",IP,"11,457.52","11,457.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,893,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$17,804.98 ",IP,"17,804.98","17,804.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,894,MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$32,041.75 ",IP,"32,041.75","32,041.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,911,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$6,729.57 ",IP,"6,729.57","6,729.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,912,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$9,964.47 ",IP,"9,964.47","9,964.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,913,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$16,613.29 ",IP,"16,613.29","16,613.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,914,OTHER MAJOR HEAD and NECK PROCEDURES,,Relative Weights,"$32,825.56 ",IP,"32,825.56","32,825.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,921,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$6,039.23 ",IP,"6,039.23","6,039.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,922,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$8,191.36 ",IP,"8,191.36","8,191.36",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,923,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$13,246.44 ",IP,"13,246.44","13,246.44",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,924,FACIAL BONE PROCEDURES EXCEPT MAJOR CRANIALFACIAL BONE PROCEDURES,,Relative Weights,"$30,839.40 ",IP,"30,839.40","30,839.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,951,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,246.53 ",IP,"4,246.53","4,246.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,952,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,953,CLEFT LIP & PALATE REPAIR,,Relative Weights,"$7,436.75 ",IP,"7,436.75","7,436.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,954,CLEFT LIP and PALATE REPAIR,,Relative Weights,"$14,987.25 ",IP,"14,987.25","14,987.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,971,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$2,853.47 ",IP,"2,853.47","2,853.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,972,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$3,981.59 ",IP,"3,981.59","3,981.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,973,TONSIL & ADENOID PROCEDURES,,Relative Weights,"$6,406.56 ",IP,"6,406.56","6,406.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,974,TONSIL and ADENOID PROCEDURES,,Relative Weights,"$15,100.30 ",IP,"15,100.30","15,100.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,981,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$4,806.30 ",IP,"4,806.30","4,806.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,982,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$6,289.73 ",IP,"6,289.73","6,289.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,983,"OTHER EAR, NOSE, MOUTH & THROAT PROCEDURES",,Relative Weights,"$10,153.46 ",IP,"10,153.46","10,153.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,984,OTHER EAR NOSE MOUTH and THROAT PROCEDURES,,Relative Weights,"$19,630.32 ",IP,"19,630.32","19,630.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1101,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,539.30 ",IP,"4,539.30","4,539.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1102,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$4,571.26 ",IP,"4,571.26","4,571.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1103,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$6,424.43 ",IP,"6,424.43","6,424.43",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1104,EAR NOSE MOUTH THROAT CRANIALFACIAL MALIGNANCIES,,Relative Weights,"$10,388.84 ",IP,"10,388.84","10,388.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1111,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,014.97 ",IP,"3,014.97","3,014.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1112,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,232.83 ",IP,"3,232.83","3,232.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1113,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$3,830.06 ",IP,"3,830.06","3,830.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1114,VERTIGO and OTHER LABYRINTH DISORDERS,,Relative Weights,"$5,856.07 ",IP,"5,856.07","5,856.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1131,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$1,710.57 ",IP,"1,710.57","1,710.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1132,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$2,449.71 ",IP,"2,449.71","2,449.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1133,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$3,709.10 ",IP,"3,709.10","3,709.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1134,INFECTIONS OF UPPER RESPIRATORY TRACT,,Relative Weights,"$7,363.91 ",IP,"7,363.91","7,363.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1141,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$2,233.23 ",IP,"2,233.23","2,233.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1142,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$3,024.94 ",IP,"3,024.94","3,024.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1143,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$4,392.57 ",IP,"4,392.57","4,392.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1144,DENTAL DISEASES AND DISORDERS,,Relative Weights,"$11,476.08 ",IP,"11,476.08","11,476.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1151,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$2,472.39 ",IP,"2,472.39","2,472.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1152,OTHER EAR NOSE MOUTHTHROAT and CRANIALFACIAL DIAGNOSES,,Relative Weights,"$3,380.25 ",IP,"3,380.25","3,380.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1153,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$4,829.66 ",IP,"4,829.66","4,829.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1154,"OTHER EAR, NOSE, MOUTH,THROAT & CRANIAL/FACIAL DIAGNOSES",,Relative Weights,"$10,560.66 ",IP,"10,560.66","10,560.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1201,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,978.60 ",IP,"8,978.60","8,978.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1202,MAJOR RESPIRATORY & CHEST PROCEDURES,,Relative Weights,"$10,724.22 ",IP,"10,724.22","10,724.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1203,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$15,096.86 ",IP,"15,096.86","15,096.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1204,MAJOR RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$30,187.20 ",IP,"30,187.20","30,187.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1211,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$6,647.79 ",IP,"6,647.79","6,647.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1212,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$8,066.62 ",IP,"8,066.62","8,066.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1213,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$12,267.10 ",IP,"12,267.10","12,267.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1214,OTHER RESPIRATORY and CHEST PROCEDURES,,Relative Weights,"$23,708.13 ",IP,"23,708.13","23,708.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1301,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$15,152.88 ",IP,"15,152.88","15,152.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1302,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,,Relative Weights,"$17,209.82 ",IP,"17,209.82","17,209.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1303,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$20,315.17 ",IP,"20,315.17","20,315.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1304,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96 HOURS,,Relative Weights,"$28,326.47 ",IP,"28,326.47","28,326.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1311,CYSTIC FIBROSIS PULMONARY DISEASE,,Relative Weights,"$6,540.23 ",IP,"6,540.23","6,540.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1312,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$9,797.46 ",IP,"9,797.46","9,797.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1313,CYSTIC FIBROSIS - PULMONARY DISEASE,,Relative Weights,"$13,253.65 ",IP,"13,253.65","13,253.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1314,CYSTIC FIBROSIS PULMONARY DISEASE,,Relative Weights,"$17,241.78 ",IP,"17,241.78","17,241.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1321,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$2,377.20 ",IP,"2,377.20","2,377.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1322,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$3,157.24 ",IP,"3,157.24","3,157.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1323,BPD & OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$5,204.90 ",IP,"5,204.90","5,204.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1324,BPD and OTH CHRONIC RESPIRATORY DISEASES ARISING IN PERINATAL PERIOD,,Relative Weights,"$9,706.75 ",IP,"9,706.75","9,706.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1331,RESPIRATORY FAILURE,,Relative Weights,"$2,072.41 ",IP,"2,072.41","2,072.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1332,RESPIRATORY FAILURE,,Relative Weights,"$3,703.26 ",IP,"3,703.26","3,703.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1333,RESPIRATORY FAILURE,,Relative Weights,"$5,064.70 ",IP,"5,064.70","5,064.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1334,RESPIRATORY FAILURE,,Relative Weights,"$9,349.38 ",IP,"9,349.38","9,349.38",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1341,PULMONARY EMBOLISM,,Relative Weights,"$2,977.18 ",IP,"2,977.18","2,977.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1342,PULMONARY EMBOLISM,,Relative Weights,"$3,832.12 ",IP,"3,832.12","3,832.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1343,PULMONARY EMBOLISM,,Relative Weights,"$5,276.03 ",IP,"5,276.03","5,276.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1344,PULMONARY EMBOLISM,,Relative Weights,"$8,166.27 ",IP,"8,166.27","8,166.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1351,MAJOR CHEST and RESPIRAZORY TRAUMA,,Relative Weights,"$3,792.26 ",IP,"3,792.26","3,792.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1352,MAJOR CHEST & RESPIRATORY TRAUMA,,Relative Weights,"$3,955.48 ",IP,"3,955.48","3,955.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1353,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$5,683.92 ",IP,"5,683.92","5,683.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1354,MAJOR CHEST and RESPIRATORY TRAUMA,,Relative Weights,"$10,178.89 ",IP,"10,178.89","10,178.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1361,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,244.47 ",IP,"4,244.47","4,244.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1362,RESPIRATORY MALIGNANCY,,Relative Weights,"$4,742.73 ",IP,"4,742.73","4,742.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1363,RESPIRATORY MALIGNANCY,,Relative Weights,"$6,049.19 ",IP,"6,049.19","6,049.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1364,RESPIRATORY MALIGNANCY,,Relative Weights,"$9,049.05 ",IP,"9,049.05","9,049.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1371,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,151.74 ",IP,"3,151.74","3,151.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1372,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$3,930.39 ",IP,"3,930.39","3,930.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1373,MAJOR RESPIRATORY INFECTIONS & INFLAMMATIONS,,Relative Weights,"$5,471.90 ",IP,"5,471.90","5,471.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1374,MAJOR RESPIRATORY INFECTIONS and INFLAMMATIONS,,Relative Weights,"$8,758.68 ",IP,"8,758.68","8,758.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1381,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$1,796.82 ",IP,"1,796.82","1,796.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1382,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$2,575.82 ",IP,"2,575.82","2,575.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1383,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$4,712.83 ",IP,"4,712.83","4,712.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1384,BRONCHIOLITIS and RSV PNEUMONIA,,Relative Weights,"$9,865.85 ",IP,"9,865.85","9,865.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1391,OTHER PNEUMONIA,,Relative Weights,"$2,182.71 ",IP,"2,182.71","2,182.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1392,OTHER PNEUMONIA,,Relative Weights,"$3,016.35 ",IP,"3,016.35","3,016.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1393,OTHER PNEUMONIA,,Relative Weights,"$4,342.75 ",IP,"4,342.75","4,342.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1394,OTHER PNEUMONIA,,Relative Weights,"$7,186.59 ",IP,"7,186.59","7,186.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1401,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$2,639.05 ",IP,"2,639.05","2,639.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1402,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,167.20 ",IP,"3,167.20","3,167.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1403,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$3,958.92 ",IP,"3,958.92","3,958.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1404,CHRONIC OBSTRUCTIVE PULMONARY DISEASE,,Relative Weights,"$5,969.47 ",IP,"5,969.47","5,969.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1411,ASTHMA,,Relative Weights,"$2,018.80 ",IP,"2,018.80","2,018.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1412,ASTHMA,,Relative Weights,"$2,763.78 ",IP,"2,763.78","2,763.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1413,ASTHMA,,Relative Weights,"$4,049.98 ",IP,"4,049.98","4,049.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1414,ASTHMA,,Relative Weights,"$6,508.28 ",IP,"6,508.28","6,508.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1421,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,358.26 ",IP,"3,358.26","3,358.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1422,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$3,679.89 ",IP,"3,679.89","3,679.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1423,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$4,888.08 ",IP,"4,888.08","4,888.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1424,INTERSTITIAL and ALVEOLAR LUNG DISEASES,,Relative Weights,"$7,901.68 ",IP,"7,901.68","7,901.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1431,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$2,504.69 ",IP,"2,504.69","2,504.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1432,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,509.11 ",IP,"3,509.11","3,509.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1433,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$5,145.11 ",IP,"5,145.11","5,145.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1434,OTHER RESPIRATORY DIAGNOSES EXCEPT SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$8,358.70 ",IP,"8,358.70","8,358.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1441,"RESPIRATORY SIGNS, SYMPTOMS & MINOR DIAGNOSES",,Relative Weights,"$2,636.99 ",IP,"2,636.99","2,636.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1442,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$3,405.68 ",IP,"3,405.68","3,405.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1443,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$4,454.42 ",IP,"4,454.42","4,454.42",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1444,RESPIRATORY SIGNS SYMPTOMS and MINOR DIAGNOSES,,Relative Weights,"$7,998.24 ",IP,"7,998.24","7,998.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1451,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,478.23 ",IP,"2,478.23","2,478.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1452,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$2,974.43 ",IP,"2,974.43","2,974.43",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1453,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$3,820.09 ",IP,"3,820.09","3,820.09",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1454,ACUTE BRONCHITIS AND RELATED SYMPTOMS,,Relative Weights,"$6,746.07 ",IP,"6,746.07","6,746.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1601,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$19,007.33 ",IP,"19,007.33","19,007.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1602,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$21,418.55 ",IP,"21,418.55","21,418.55",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1603,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$29,897.52 ",IP,"29,897.52","29,897.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1604,MAJOR CARDIOTHORACIC REPAIR OF HEART ANOMALY,,Relative Weights,"$58,616.75 ",IP,"58,616.75","58,616.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1611,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$21,623.70 ",IP,"21,623.70","21,623.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1612,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$25,324.21 ",IP,"25,324.21","25,324.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1613,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$37,168.99 ",IP,"37,168.99","37,168.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1614,CARDIAC DEFIBRILLATOR and HEART ASSIST IMPLANT,,Relative Weights,"$84,952.59 ",IP,"84,952.59","84,952.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1621,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$21,734.00 ",IP,"21,734.00","21,734.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1622,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$25,647.21 ",IP,"25,647.21","25,647.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1623,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$32,557.19 ",IP,"32,557.19","32,557.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1624,CARDIAC VALVE PROCEDURES W AMI OR COMPLEX PDX,,Relative Weights,"$51,493.39 ",IP,"51,493.39","51,493.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1631,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$18,870.57 ",IP,"18,870.57","18,870.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1632,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$20,678.38 ",IP,"20,678.38","20,678.38",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1633,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$25,441.73 ",IP,"25,441.73","25,441.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1634,CARDIAC VALVE PROCEDURES WO AMI OR COMPLEX PDX,,Relative Weights,"$42,290.40 ",IP,"42,290.40","42,290.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1651,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$17,424.93 ",IP,"17,424.93","17,424.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1652,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$20,592.13 ",IP,"20,592.13","20,592.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1653,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$24,876.46 ",IP,"24,876.46","24,876.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1654,CORONARY BYPASS W AMI OR COMPLEX PDX,,Relative Weights,"$37,414.00 ",IP,"37,414.00","37,414.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1661,CORONARY BYPASS W/O AMI OR COMPLEX PDX,,Relative Weights,"$16,087.19 ",IP,"16,087.19","16,087.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1662,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$17,173.40 ",IP,"17,173.40","17,173.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1663,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$20,743.67 ",IP,"20,743.67","20,743.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1664,CORONARY BYPASS WO AMI OR COMPLEX PDX,,Relative Weights,"$33,503.88 ",IP,"33,503.88","33,503.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1671,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$15,753.88 ",IP,"15,753.88","15,753.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1672,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$16,654.52 ",IP,"16,654.52","16,654.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1673,OTHER CARDIOTHORACIC & THORACIC VASCULAR PROCEDURES,,Relative Weights,"$20,943.66 ",IP,"20,943.66","20,943.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1674,OTHER CARDIOTHORACIC and THORACIC VASCULAR PROCEDURES,,Relative Weights,"$39,564.41 ",IP,"39,564.41","39,564.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1691,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$9,314.67 ",IP,"9,314.67","9,314.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1692,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$12,244.08 ",IP,"12,244.08","12,244.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1693,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$19,456.45 ",IP,"19,456.45","19,456.45",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1694,MAJOR ABDOMINAL VASCULAR PROCEDURES,,Relative Weights,"$33,906.95 ",IP,"33,906.95","33,906.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1701,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,265.14 ",IP,"10,265.14","10,265.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1702,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,949.99 ",IP,"10,949.99","10,949.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1703,PERMANENT CARDIAC PACEMAKER IMPLANT W AMI HEART FAILURE OR SHOCK,,Relative Weights,"$13,975.61 ",IP,"13,975.61","13,975.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1704,"PERMANENT CARDIAC PACEMAKER IMPLANT W AMI, HEART FAILURE OR SHOCK",,Relative Weights,"$19,895.26 ",IP,"19,895.26","19,895.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1711,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$8,272.45 ",IP,"8,272.45","8,272.45",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1712,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$9,180.66 ",IP,"9,180.66","9,180.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1713,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$10,971.29 ",IP,"10,971.29","10,971.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1714,PERM CARDIAC PACEMAKER IMPLANT WO AMI HEART FAILURE OR SHOCK,,Relative Weights,"$17,965.80 ",IP,"17,965.80","17,965.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1741,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$9,597.47 ",IP,"9,597.47","9,597.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1742,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$10,364.10 ",IP,"10,364.10","10,364.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1743,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$12,874.29 ",IP,"12,874.29","12,874.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1744,PERCUTANEOUS CORONARY INTERVENTION W AMI,,Relative Weights,"$19,364.01 ",IP,"19,364.01","19,364.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1751,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$11,256.84 ",IP,"11,256.84","11,256.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1752,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$12,009.39 ",IP,"12,009.39","12,009.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1753,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$14,253.95 ",IP,"14,253.95","14,253.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1754,PERCUTANEOUS CORONARY INTERVENTION WO AMI,,Relative Weights,"$25,147.58 ",IP,"25,147.58","25,147.58",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1761,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$9,268.97 ",IP,"9,268.97","9,268.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1762,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$10,537.63 ",IP,"10,537.63","10,537.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1763,CARDIAC PACEMAKER & DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$15,961.08 ",IP,"15,961.08","15,961.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1764,CARDIAC PACEMAKER and DEFIBRILLATOR DEVICE REPLACEMENT,,Relative Weights,"$25,961.29 ",IP,"25,961.29","25,961.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1771,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$6,530.96 ",IP,"6,530.96","6,530.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1772,CARDIAC PACEMAKER and DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$9,029.80 ",IP,"9,029.80","9,029.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1773,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$11,280.21 ",IP,"11,280.21","11,280.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1774,CARDIAC PACEMAKER & DEFIBRILLATOR REVISION EXCEPT DEVICE REPLACEMENT,,Relative Weights,"$17,033.20 ",IP,"17,033.20","17,033.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1801,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$6,351.58 ",IP,"6,351.58","6,351.58",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1802,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$7,715.78 ",IP,"7,715.78","7,715.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1803,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$10,872.33 ",IP,"10,872.33","10,872.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1804,OTHER CIRCULATORY SYSTEM PROCEDURES,,Relative Weights,"$20,062.95 ",IP,"20,062.95","20,062.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1811,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$9,268.28 ",IP,"9,268.28","9,268.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1812,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$11,438.97 ",IP,"11,438.97","11,438.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1813,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$16,303.68 ",IP,"16,303.68","16,303.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1814,LOWER EXTREMITY ARTERIAL PROCEDURES,,Relative Weights,"$27,105.22 ",IP,"27,105.22","27,105.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1821,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$9,585.79 ",IP,"9,585.79","9,585.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1822,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$11,451.68 ",IP,"11,451.68","11,451.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1823,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$12,966.73 ",IP,"12,966.73","12,966.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1824,OTHER PERIPHERAL VASCULAR PROCEDURES,,Relative Weights,"$25,526.94 ",IP,"25,526.94","25,526.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1901,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$3,454.82 ",IP,"3,454.82","3,454.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1902,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$4,023.17 ",IP,"4,023.17","4,023.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1903,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$5,278.78 ",IP,"5,278.78","5,278.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1904,ACUTE MYOCARDIAL INFARCTION,,Relative Weights,"$8,568.66 ",IP,"8,568.66","8,568.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1911,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$4,795.99 ",IP,"4,795.99","4,795.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1912,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$5,349.23 ",IP,"5,349.23","5,349.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1913,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$6,652.26 ",IP,"6,652.26","6,652.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1914,CARDIAC CATHETERIZATION FOR CORONARY ARTERY DISEASE,,Relative Weights,"$10,568.22 ",IP,"10,568.22","10,568.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1921,CARDIAC CATHETERIZATION FOR OTHER NON-CORONARY CONDITIONS,,Relative Weights,"$5,126.56 ",IP,"5,126.56","5,126.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1922,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$5,995.59 ",IP,"5,995.59","5,995.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1923,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$8,192.04 ",IP,"8,192.04","8,192.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1924,CARDIAC CATHETERIZATION FOR OTHER NONCORONARY CONDITIONS,,Relative Weights,"$14,030.25 ",IP,"14,030.25","14,030.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1931,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$4,156.16 ",IP,"4,156.16","4,156.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1932,ACUTE & SUBACUTE ENDOCARDITIS,,Relative Weights,"$5,201.81 ",IP,"5,201.81","5,201.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1933,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$7,472.15 ",IP,"7,472.15","7,472.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1934,ACUTE and SUBACUTE ENDOCARDITIS,,Relative Weights,"$12,655.75 ",IP,"12,655.75","12,655.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1941,HEART FAILURE,,Relative Weights,"$2,590.60 ",IP,"2,590.60","2,590.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1942,HEART FAILURE,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1943,HEART FAILURE,,Relative Weights,"$4,368.86 ",IP,"4,368.86","4,368.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1944,HEART FAILURE,,Relative Weights,"$7,070.79 ",IP,"7,070.79","7,070.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1961,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,365.52 ",IP,"2,365.52","2,365.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1962,CARDIAC ARREST and SHOCK,,Relative Weights,"$2,596.44 ",IP,"2,596.44","2,596.44",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1963,CARDIAC ARREST & SHOCK,,Relative Weights,"$4,010.12 ",IP,"4,010.12","4,010.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1964,CARDIAC ARREST & SHOCK,,Relative Weights,"$8,325.03 ",IP,"8,325.03","8,325.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1971,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$2,758.63 ",IP,"2,758.63","2,758.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1972,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$3,488.49 ",IP,"3,488.49","3,488.49",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1973,PERIPHERAL and OTHER VASCULAR DISORDERS,,Relative Weights,"$4,794.61 ",IP,"4,794.61","4,794.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1974,PERIPHERAL & OTHER VASCULAR DISORDERS,,Relative Weights,"$9,053.51 ",IP,"9,053.51","9,053.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1981,ANGINA PECTORIS & CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,680.28 ",IP,"2,680.28","2,680.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1982,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$2,985.77 ",IP,"2,985.77","2,985.77",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1983,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$3,628.00 ",IP,"3,628.00","3,628.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1984,ANGINA PECTORIS and CORONARY ATHEROSCLEROSIS,,Relative Weights,"$6,763.25 ",IP,"6,763.25","6,763.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1991,HYPERTENSION,,Relative Weights,"$2,662.41 ",IP,"2,662.41","2,662.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1992,HYPERTENSION,,Relative Weights,"$2,956.56 ",IP,"2,956.56","2,956.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1993,HYPERTENSION,,Relative Weights,"$3,736.93 ",IP,"3,736.93","3,736.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,1994,HYPERTENSION,,Relative Weights,"$6,634.39 ",IP,"6,634.39","6,634.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2001,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$2,919.45 ",IP,"2,919.45","2,919.45",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2002,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$3,565.12 ",IP,"3,565.12","3,565.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2003,CARDIAC STRUCTURAL & VALVULAR DISORDERS,,Relative Weights,"$4,853.03 ",IP,"4,853.03","4,853.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2004,CARDIAC STRUCTURAL and VALVULAR DISORDERS,,Relative Weights,"$10,524.92 ",IP,"10,524.92","10,524.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2011,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,322.91 ",IP,"2,322.91","2,322.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2012,CARDIAC ARRHYTHMIA and CONDUCTION DISORDERS,,Relative Weights,"$2,865.50 ",IP,"2,865.50","2,865.50",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2013,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$3,988.81 ",IP,"3,988.81","3,988.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2014,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS,,Relative Weights,"$7,490.70 ",IP,"7,490.70","7,490.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2031,CHEST PAIN,,Relative Weights,"$2,896.08 ",IP,"2,896.08","2,896.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2032,CHEST PAIN,,Relative Weights,"$3,156.55 ",IP,"3,156.55","3,156.55",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2033,CHEST PAIN,,Relative Weights,"$3,647.25 ",IP,"3,647.25","3,647.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2034,CHEST PAIN,,Relative Weights,"$5,656.08 ",IP,"5,656.08","5,656.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2041,SYNCOPE and COLLAPSE,,Relative Weights,"$3,210.15 ",IP,"3,210.15","3,210.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2042,SYNCOPE and COLLAPSE,,Relative Weights,"$3,469.25 ",IP,"3,469.25","3,469.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2043,SYNCOPE and COLLAPSE,,Relative Weights,"$3,913.56 ",IP,"3,913.56","3,913.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2044,SYNCOPE and COLLAPSE,,Relative Weights,"$6,621.67 ",IP,"6,621.67","6,621.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2051,CARDIOMYOPATHY,,Relative Weights,"$3,094.70 ",IP,"3,094.70","3,094.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2052,CARDIOMYOPATHY,,Relative Weights,"$3,108.78 ",IP,"3,108.78","3,108.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2053,CARDIOMYOPATHY,,Relative Weights,"$4,834.47 ",IP,"4,834.47","4,834.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2054,CARDIOMYOPATHY,,Relative Weights,"$12,099.76 ",IP,"12,099.76","12,099.76",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2061,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$3,915.62 ",IP,"3,915.62","3,915.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2062,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$4,064.41 ",IP,"4,064.41","4,064.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2063,"MALFUNCTION,REACTION,COMPLICATION OF CARDIAC/VASC DEVICE OR PROCEDURE",,Relative Weights,"$5,616.22 ",IP,"5,616.22","5,616.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2064,MALFUNCTIONREACTIONCOMPLICATION OF CARDIACVASC DEVICE OR PROCEDURE,,Relative Weights,"$11,629.68 ",IP,"11,629.68","11,629.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2071,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$2,947.97 ",IP,"2,947.97","2,947.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2072,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$3,511.17 ",IP,"3,511.17","3,511.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2073,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$4,590.50 ",IP,"4,590.50","4,590.50",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2074,OTHER CIRCULATORY SYSTEM DIAGNOSES,,Relative Weights,"$8,837.72 ",IP,"8,837.72","8,837.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2201,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$7,004.47 ",IP,"7,004.47","7,004.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2202,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$10,124.94 ",IP,"10,124.94","10,124.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2203,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$15,446.33 ",IP,"15,446.33","15,446.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2204,MAJOR STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$29,728.80 ",IP,"29,728.80","29,728.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2221,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$3,629.38 ",IP,"3,629.38","3,629.38",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2222,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$5,962.94 ",IP,"5,962.94","5,962.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2223,OTHER STOMACH ESOPHAGEAL and DUODENAL PROCEDURES,,Relative Weights,"$9,116.74 ",IP,"9,116.74","9,116.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2224,"OTHER STOMACH, ESOPHAGEAL & DUODENAL PROCEDURES",,Relative Weights,"$19,946.46 ",IP,"19,946.46","19,946.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2231,OTHER SMALL & LARGE BOWEL PROCEDURES,,Relative Weights,"$5,180.51 ",IP,"5,180.51","5,180.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2232,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$7,107.90 ",IP,"7,107.90","7,107.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2233,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$10,759.27 ",IP,"10,759.27","10,759.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2234,OTHER SMALL and LARGE BOWEL PROCEDURES,,Relative Weights,"$20,449.53 ",IP,"20,449.53","20,449.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2241,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$6,143.69 ",IP,"6,143.69","6,143.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2242,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$7,746.36 ",IP,"7,746.36","7,746.36",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2243,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$11,242.41 ",IP,"11,242.41","11,242.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2244,PERITONEAL ADHESIOLYSIS,,Relative Weights,"$20,422.04 ",IP,"20,422.04","20,422.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2261,ANAL PROCEDURES,,Relative Weights,"$4,263.71 ",IP,"4,263.71","4,263.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2262,ANAL PROCEDURES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2263,ANAL PROCEDURES,,Relative Weights,"$7,950.47 ",IP,"7,950.47","7,950.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2264,ANAL PROCEDURES,,Relative Weights,"$17,017.73 ",IP,"17,017.73","17,017.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2271,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$5,689.07 ",IP,"5,689.07","5,689.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2272,HERNIA PROCEDURES EXCEPT INGUINAL FEMORAL and UMBILICAL,,Relative Weights,"$6,795.89 ",IP,"6,795.89","6,795.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2273,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$10,114.97 ",IP,"10,114.97","10,114.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2274,"HERNIA PROCEDURES EXCEPT INGUINAL, FEMORAL & UMBILICAL",,Relative Weights,"$20,038.21 ",IP,"20,038.21","20,038.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2281,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$4,335.53 ",IP,"4,335.53","4,335.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2282,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$5,502.48 ",IP,"5,502.48","5,502.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2283,INGUINAL FEMORAL and UMBILICAL HERNIA PROCEDURES,,Relative Weights,"$7,788.28 ",IP,"7,788.28","7,788.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2284,"INGUINAL, FEMORAL & UMBILICAL HERNIA PROCEDURES",,Relative Weights,"$16,501.95 ",IP,"16,501.95","16,501.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2291,OTHER DIGESTIVE SYSTEM & ABDOMINAL PROCEDURES,,Relative Weights,"$5,564.34 ",IP,"5,564.34","5,564.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2292,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$7,117.87 ",IP,"7,117.87","7,117.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2293,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$10,259.30 ",IP,"10,259.30","10,259.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2294,OTHER DIGESTIVE SYSTEM and ABDOMINAL PROCEDURES,,Relative Weights,"$20,018.28 ",IP,"20,018.28","20,018.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2301,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$6,770.12 ",IP,"6,770.12","6,770.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2302,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$8,787.20 ",IP,"8,787.20","8,787.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2303,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$13,506.56 ",IP,"13,506.56","13,506.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2304,MAJOR SMALL BOWEL PROCEDURES,,Relative Weights,"$27,168.10 ",IP,"27,168.10","27,168.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2311,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$6,900.01 ",IP,"6,900.01","6,900.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2312,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$8,451.83 ",IP,"8,451.83","8,451.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2313,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$12,656.43 ",IP,"12,656.43","12,656.43",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2314,MAJOR LARGE BOWEL PROCEDURES,,Relative Weights,"$23,212.62 ",IP,"23,212.62","23,212.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2321,GASTRIC FUNDOPLICATION,,Relative Weights,"$5,317.96 ",IP,"5,317.96","5,317.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2322,GASTRIC FUNDOPLICATION,,Relative Weights,"$6,619.27 ",IP,"6,619.27","6,619.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2323,GASTRIC FUNDOPLICATION,,Relative Weights,"$9,668.60 ",IP,"9,668.60","9,668.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2324,GASTRIC FUNDOPLICATION,,Relative Weights,"$26,510.06 ",IP,"26,510.06","26,510.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2331,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,328.61 ",IP,"5,328.61","5,328.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2332,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,525.46 ",IP,"6,525.46","6,525.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2333,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,426.35 ",IP,"9,426.35","9,426.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2334,APPENDECTOMY WITH COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$16,969.28 ",IP,"16,969.28","16,969.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2341,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2342,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,853.72 ",IP,"4,853.72","4,853.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2343,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,767.67 ",IP,"7,767.67","7,767.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2344,APPENDECTOMY WITHOUT COMPLEX PRINCIPAL DIAGNOSIS,,Relative Weights,"$15,153.91 ",IP,"15,153.91","15,153.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2401,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,130.38 ",IP,"4,130.38","4,130.38",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2402,DIGESTIVE MALIGNANCY,,Relative Weights,"$4,471.61 ",IP,"4,471.61","4,471.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2403,DIGESTIVE MALIGNANCY,,Relative Weights,"$5,940.95 ",IP,"5,940.95","5,940.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2404,DIGESTIVE MALIGNANCY,,Relative Weights,"$10,480.94 ",IP,"10,480.94","10,480.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2411,PEPTIC ULCER & GASTRITIS,,Relative Weights,"$3,142.46 ",IP,"3,142.46","3,142.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2412,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$3,833.49 ",IP,"3,833.49","3,833.49",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2413,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2414,PEPTIC ULCER and GASTRITIS,,Relative Weights,"$11,497.38 ",IP,"11,497.38","11,497.38",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2421,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$2,834.23 ",IP,"2,834.23","2,834.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2422,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$3,630.75 ",IP,"3,630.75","3,630.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2423,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$5,095.29 ",IP,"5,095.29","5,095.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2424,MAJOR ESOPHAGEAL DISORDERS,,Relative Weights,"$11,235.54 ",IP,"11,235.54","11,235.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2431,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$2,619.12 ",IP,"2,619.12","2,619.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2432,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$3,394.34 ",IP,"3,394.34","3,394.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2433,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$4,672.28 ",IP,"4,672.28","4,672.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2434,OTHER ESOPHAGEAL DISORDERS,,Relative Weights,"$10,028.72 ",IP,"10,028.72","10,028.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2441,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$2,541.46 ",IP,"2,541.46","2,541.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2442,DIVERTICULITIS and DIVERTICULOSIS,,Relative Weights,"$3,268.57 ",IP,"3,268.57","3,268.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2443,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$4,670.91 ",IP,"4,670.91","4,670.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2444,DIVERTICULITIS & DIVERTICULOSIS,,Relative Weights,"$10,075.80 ",IP,"10,075.80","10,075.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2451,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,109.82 ",IP,"3,109.82","3,109.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2452,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$3,884.35 ",IP,"3,884.35","3,884.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2453,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$5,370.53 ",IP,"5,370.53","5,370.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2454,INFLAMMATORY BOWEL DISEASE,,Relative Weights,"$12,127.25 ",IP,"12,127.25","12,127.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2461,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,009.82 ",IP,"3,009.82","3,009.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2462,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$3,644.84 ",IP,"3,644.84","3,644.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2463,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$5,068.14 ",IP,"5,068.14","5,068.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2464,GASTROINTESTINAL VASCULAR INSUFFICIENCY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2471,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,323.60 ",IP,"2,323.60","2,323.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2472,INTESTINAL OBSTRUCTION,,Relative Weights,"$2,999.17 ",IP,"2,999.17","2,999.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2473,INTESTINAL OBSTRUCTION,,Relative Weights,"$4,431.74 ",IP,"4,431.74","4,431.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2474,INTESTINAL OBSTRUCTION,,Relative Weights,"$9,108.15 ",IP,"9,108.15","9,108.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2481,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$2,573.42 ",IP,"2,573.42","2,573.42",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2482,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$3,590.89 ",IP,"3,590.89","3,590.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2483,MAJOR GASTROINTESTINAL & PERITONEAL INFECTIONS,,Relative Weights,"$4,839.63 ",IP,"4,839.63","4,839.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2484,MAJOR GASTROINTESTINAL and PERITONEAL INFECTIONS,,Relative Weights,"$10,133.19 ",IP,"10,133.19","10,133.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2491,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,187.52 ",IP,"2,187.52","2,187.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2492,OTHER GASTROENTERITIS NAUSEA and VOMITING,,Relative Weights,"$2,797.80 ",IP,"2,797.80","2,797.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2493,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$3,754.80 ",IP,"3,754.80","3,754.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2494,"OTHER GASTROENTERITIS, NAUSEA & VOMITING",,Relative Weights,"$8,298.22 ",IP,"8,298.22","8,298.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2511,ABDOMINAL PAIN,,Relative Weights,"$2,520.84 ",IP,"2,520.84","2,520.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2512,ABDOMINAL PAIN,,Relative Weights,"$3,175.79 ",IP,"3,175.79","3,175.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2513,ABDOMINAL PAIN,,Relative Weights,"$4,112.86 ",IP,"4,112.86","4,112.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2514,ABDOMINAL PAIN,,Relative Weights,"$7,334.01 ",IP,"7,334.01","7,334.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2521,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$2,913.26 ",IP,"2,913.26","2,913.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2522,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$3,639.34 ",IP,"3,639.34","3,639.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2523,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$5,172.60 ",IP,"5,172.60","5,172.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2524,MALFUNCTION REACTION and COMPLICATION OF GI DEVICE OR PROCEDURE,,Relative Weights,"$11,168.53 ",IP,"11,168.53","11,168.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2531,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$2,890.24 ",IP,"2,890.24","2,890.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2532,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$3,602.23 ",IP,"3,602.23","3,602.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2533,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$5,054.39 ",IP,"5,054.39","5,054.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2534,OTHER and UNSPECIFIED GASTROINTESTINAL HEMORRHAGE,,Relative Weights,"$9,586.48 ",IP,"9,586.48","9,586.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2541,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$2,614.99 ",IP,"2,614.99","2,614.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2542,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$3,386.43 ",IP,"3,386.43","3,386.43",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2543,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$4,771.93 ",IP,"4,771.93","4,771.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2544,OTHER DIGESTIVE SYSTEM DIAGNOSES,,Relative Weights,"$9,778.91 ",IP,"9,778.91","9,778.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2601,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$9,438.72 ",IP,"9,438.72","9,438.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2602,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$11,500.13 ",IP,"11,500.13","11,500.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2603,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$16,312.61 ",IP,"16,312.61","16,312.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2604,MAJOR PANCREAS LIVER and SHUNT PROCEDURES,,Relative Weights,"$34,324.11 ",IP,"34,324.11","34,324.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2611,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$6,801.05 ",IP,"6,801.05","6,801.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2612,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$10,119.10 ",IP,"10,119.10","10,119.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2613,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$14,491.05 ",IP,"14,491.05","14,491.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2614,MAJOR BILIARY TRACT PROCEDURES,,Relative Weights,"$28,576.97 ",IP,"28,576.97","28,576.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2631,CHOLECYSTECTOMY,,Relative Weights,"$5,153.36 ",IP,"5,153.36","5,153.36",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2632,CHOLECYSTECTOMY,,Relative Weights,"$6,574.60 ",IP,"6,574.60","6,574.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2633,CHOLECYSTECTOMY,,Relative Weights,"$8,823.28 ",IP,"8,823.28","8,823.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2634,CHOLECYSTECTOMY,,Relative Weights,"$16,983.37 ",IP,"16,983.37","16,983.37",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2641,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$6,826.47 ",IP,"6,826.47","6,826.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2642,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$7,584.86 ",IP,"7,584.86","7,584.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2643,"OTHER HEPATOBILIARY, PANCREAS & ABDOMINAL PROCEDURES",,Relative Weights,"$11,612.15 ",IP,"11,612.15","11,612.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2644,OTHER HEPATOBILIARY PANCREAS and ABDOMINAL PROCEDURES,,Relative Weights,"$29,218.86 ",IP,"29,218.86","29,218.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2791,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$2,567.92 ",IP,"2,567.92","2,567.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2792,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$3,323.89 ",IP,"3,323.89","3,323.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2793,HEPATIC COMA & OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$4,704.93 ",IP,"4,704.93","4,704.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2794,HEPATIC COMA and OTHER MAJOR ACUTE LIVER DISORDERS,,Relative Weights,"$11,290.86 ",IP,"11,290.86","11,290.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2801,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$2,499.54 ",IP,"2,499.54","2,499.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2802,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$3,093.32 ",IP,"3,093.32","3,093.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2803,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$4,638.26 ",IP,"4,638.26","4,638.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2804,ALCOHOLIC LIVER DISEASE,,Relative Weights,"$10,324.24 ",IP,"10,324.24","10,324.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2811,MALIGNANCY OF HEPATOBILIARY SYSTEM & PANCREAS,,Relative Weights,"$3,619.41 ",IP,"3,619.41","3,619.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2812,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2813,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$5,844.73 ",IP,"5,844.73","5,844.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2814,MALIGNANCY OF HEPATOBILIARY SYSTEM and PANCREAS,,Relative Weights,"$9,186.50 ",IP,"9,186.50","9,186.50",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2821,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$2,462.42 ",IP,"2,462.42","2,462.42",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2822,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$3,135.24 ",IP,"3,135.24","3,135.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2823,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$4,746.16 ",IP,"4,746.16","4,746.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2824,DISORDERS OF PANCREAS EXCEPT MALIGNANCY,,Relative Weights,"$12,503.18 ",IP,"12,503.18","12,503.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2831,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$2,720.83 ",IP,"2,720.83","2,720.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2832,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$3,349.67 ",IP,"3,349.67","3,349.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2833,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$4,885.67 ",IP,"4,885.67","4,885.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2834,OTHER DISORDERS OF THE LIVER,,Relative Weights,"$10,248.65 ",IP,"10,248.65","10,248.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2841,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$3,351.73 ",IP,"3,351.73","3,351.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2842,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$4,147.57 ",IP,"4,147.57","4,147.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2843,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$5,552.31 ",IP,"5,552.31","5,552.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,2844,DISORDERS OF GALLBLADDER and BILIARY TRACT,,Relative Weights,"$10,788.48 ",IP,"10,788.48","10,788.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3011,HIP JOINT REPLACEMENT,,Relative Weights,"$7,771.10 ",IP,"7,771.10","7,771.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3012,HIP JOINT REPLACEMENT,,Relative Weights,"$8,122.29 ",IP,"8,122.29","8,122.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3013,HIP JOINT REPLACEMENT,,Relative Weights,"$10,480.59 ",IP,"10,480.59","10,480.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3014,HIP JOINT REPLACEMENT,,Relative Weights,"$16,617.41 ",IP,"16,617.41","16,617.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3021,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,208.24 ",IP,"7,208.24","7,208.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3022,KNEE JOINT REPLACEMENT,,Relative Weights,"$7,702.03 ",IP,"7,702.03","7,702.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3023,KNEE JOINT REPLACEMENT,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3024,KNEE JOINT REPLACEMENT,,Relative Weights,"$17,075.12 ",IP,"17,075.12","17,075.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3031,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$22,622.27 ",IP,"22,622.27","22,622.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3032,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$26,401.82 ",IP,"26,401.82","26,401.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3033,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$36,462.15 ",IP,"36,462.15","36,462.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3034,DORSAL and LUMBAR FUSION PROC FOR CURVATURE OF BACK,,Relative Weights,"$46,680.22 ",IP,"46,680.22","46,680.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3041,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$13,662.91 ",IP,"13,662.91","13,662.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3042,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$15,568.66 ",IP,"15,568.66","15,568.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3043,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$23,409.86 ",IP,"23,409.86","23,409.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3044,DORSAL and LUMBAR FUSION PROC EXCEPT FOR CURVATURE OF BACK,,Relative Weights,"$37,522.24 ",IP,"37,522.24","37,522.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3051,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$4,866.09 ",IP,"4,866.09","4,866.09",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3052,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$6,637.82 ",IP,"6,637.82","6,637.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3053,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$10,080.61 ",IP,"10,080.61","10,080.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3054,AMPUTATION OF LOWER LIMB EXCEPT TOES,,Relative Weights,"$19,786.33 ",IP,"19,786.33","19,786.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3081,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$6,633.70 ",IP,"6,633.70","6,633.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3082,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$7,529.88 ",IP,"7,529.88","7,529.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3083,HIP & FEMUR FRACTURE REPAIR,,Relative Weights,"$9,249.72 ",IP,"9,249.72","9,249.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3084,HIP and FEMUR FRACTURE REPAIR,,Relative Weights,"$14,744.30 ",IP,"14,744.30","14,744.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3091,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$7,238.83 ",IP,"7,238.83","7,238.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3092,OTHER SIGNIFICANT HIP and FEMUR SURGERY,,Relative Weights,"$9,130.83 ",IP,"9,130.83","9,130.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3093,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$12,063.33 ",IP,"12,063.33","12,063.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3094,OTHER SIGNIFICANT HIP & FEMUR SURGERY,,Relative Weights,"$21,019.95 ",IP,"21,019.95","21,019.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3101,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$5,634.78 ",IP,"5,634.78","5,634.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3102,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$6,775.27 ",IP,"6,775.27","6,775.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3103,INTERVERTEBRAL DISC EXCISION and DECOMPRESSION,,Relative Weights,"$9,328.07 ",IP,"9,328.07","9,328.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3104,INTERVERTEBRAL DISC EXCISION & DECOMPRESSION,,Relative Weights,"$18,301.18 ",IP,"18,301.18","18,301.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3121,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$6,515.49 ",IP,"6,515.49","6,515.49",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3122,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,587.21 ",IP,"8,587.21","8,587.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3123,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$12,636.50 ",IP,"12,636.50","12,636.50",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3124,SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$31,602.60 ",IP,"31,602.60","31,602.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3131,KNEE & LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$5,906.59 ",IP,"5,906.59","5,906.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3132,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$7,791.03 ",IP,"7,791.03","7,791.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3133,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$10,674.40 ",IP,"10,674.40","10,674.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3134,KNEE and LOWER LEG PROCEDURES EXCEPT FOOT,,Relative Weights,"$18,704.94 ",IP,"18,704.94","18,704.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3141,FOOT & TOE PROCEDURES,,Relative Weights,"$5,184.29 ",IP,"5,184.29","5,184.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3142,FOOT and TOE PROCEDURES,,Relative Weights,"$5,760.89 ",IP,"5,760.89","5,760.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3143,FOOT and TOE PROCEDURES,,Relative Weights,"$7,587.61 ",IP,"7,587.61","7,587.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3144,FOOT and TOE PROCEDURES,,Relative Weights,"$15,541.86 ",IP,"15,541.86","15,541.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3151,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$4,407.35 ",IP,"4,407.35","4,407.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3152,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$7,204.46 ",IP,"7,204.46","7,204.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3153,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$9,814.99 ",IP,"9,814.99","9,814.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3154,SHOULDER UPPER ARM and FOREARM PROCEDURES EXCEPT JOINT REPLACEMENT,,Relative Weights,"$17,630.42 ",IP,"17,630.42","17,630.42",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3161,HAND and WRIST PROCEDURES,,Relative Weights,"$4,228.66 ",IP,"4,228.66","4,228.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3162,HAND and WRIST PROCEDURES,,Relative Weights,"$5,513.82 ",IP,"5,513.82","5,513.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3163,HAND and WRIST PROCEDURES,,Relative Weights,"$8,327.78 ",IP,"8,327.78","8,327.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3164,HAND and WRIST PROCEDURES,,Relative Weights,"$17,742.44 ",IP,"17,742.44","17,742.44",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3171,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$4,914.20 ",IP,"4,914.20","4,914.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3172,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$6,410.69 ",IP,"6,410.69","6,410.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3173,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$9,611.56 ",IP,"9,611.56","9,611.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3174,TENDON MUSCLE and OTHER SOFT TISSUE PROCEDURES,,Relative Weights,"$20,290.08 ",IP,"20,290.08","20,290.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3201,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$5,415.55 ",IP,"5,415.55","5,415.55",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3202,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$6,995.19 ",IP,"6,995.19","6,995.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3203,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$10,390.22 ",IP,"10,390.22","10,390.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3204,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE PROCEDURES,,Relative Weights,"$19,965.01 ",IP,"19,965.01","19,965.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3211,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$8,441.17 ",IP,"8,441.17","8,441.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3212,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$10,023.57 ",IP,"10,023.57","10,023.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3213,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$14,027.50 ",IP,"14,027.50","14,027.50",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3214,CERVICAL SPINAL FUSION and OTHER BACKNECK PROC EXC DISC EXCISDECOMP,,Relative Weights,"$25,569.90 ",IP,"25,569.90","25,569.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3221,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,466.60 ",IP,"8,466.60","8,466.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3222,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3223,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$11,526.59 ",IP,"11,526.59","11,526.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3224,SHOULDER and ELBOW JOINT REPLACEMENT,,Relative Weights,"$17,494.69 ",IP,"17,494.69","17,494.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3401,FRACTURE OF FEMUR,,Relative Weights,"$2,284.43 ",IP,"2,284.43","2,284.43",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3402,FRACTURE OF FEMUR,,Relative Weights,"$2,649.70 ",IP,"2,649.70","2,649.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3403,FRACTURE OF FEMUR,,Relative Weights,"$3,664.08 ",IP,"3,664.08","3,664.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3404,FRACTURE OF FEMUR,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3411,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,584.41 ",IP,"2,584.41","2,584.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3412,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$2,958.62 ",IP,"2,958.62","2,958.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3413,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$3,751.71 ",IP,"3,751.71","3,751.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3414,FRACTURE OF PELVIS OR DISLOCATION OF HIP,,Relative Weights,"$8,259.05 ",IP,"8,259.05","8,259.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3421,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$2,677.53 ",IP,"2,677.53","2,677.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3422,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$3,262.04 ",IP,"3,262.04","3,262.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3423,"FRACTURES & DISLOCATIONS EXCEPT FEMUR, PELVIS & BACK",,Relative Weights,"$4,236.57 ",IP,"4,236.57","4,236.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3424,FRACTURES and DISLOCATIONS EXCEPT FEMUR PELVIS and BACK,,Relative Weights,"$8,410.59 ",IP,"8,410.59","8,410.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3431,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,528.30 ",IP,"4,528.30","4,528.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3432,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$4,916.60 ",IP,"4,916.60","4,916.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3433,MUSCULOSKELETAL MALIGNANCY & PATHOL FRACTURE D/T MUSCSKEL MALIG,,Relative Weights,"$6,907.57 ",IP,"6,907.57","6,907.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3434,MUSCULOSKELETAL MALIGNANCY and PATHOL FRACTURE DT MUSCSKEL MALIG,,Relative Weights,"$11,710.09 ",IP,"11,710.09","11,710.09",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3441,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$3,603.61 ",IP,"3,603.61","3,603.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3442,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$4,272.99 ",IP,"4,272.99","4,272.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3443,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$5,859.85 ",IP,"5,859.85","5,859.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3444,OSTEOMYELITIS SEPTIC ARTHRITIS and OTHER MUSCULOSKELETAL INFECTIONS,,Relative Weights,"$10,885.73 ",IP,"10,885.73","10,885.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3461,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$3,601.54 ",IP,"3,601.54","3,601.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3462,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$4,539.99 ",IP,"4,539.99","4,539.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3463,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$6,445.74 ",IP,"6,445.74","6,445.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3464,CONNECTIVE TISSUE DISORDERS,,Relative Weights,"$15,116.11 ",IP,"15,116.11","15,116.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3471,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$3,279.91 ",IP,"3,279.91","3,279.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3472,"OTHER BACK & NECK DISORDERS, FRACTURES & INJURIES",,Relative Weights,"$3,772.33 ",IP,"3,772.33","3,772.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3473,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$4,894.95 ",IP,"4,894.95","4,894.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3474,OTHER BACK and NECK DISORDERS FRACTURES and INJURIES,,Relative Weights,"$9,864.13 ",IP,"9,864.13","9,864.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3491,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$2,603.31 ",IP,"2,603.31","2,603.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3492,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$3,535.91 ",IP,"3,535.91","3,535.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3493,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$5,006.97 ",IP,"5,006.97","5,006.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3494,MALFUNCTION REACTION COMPLIC OF ORTHOPEDIC DEVICE OR PROCEDURE,,Relative Weights,"$9,666.89 ",IP,"9,666.89","9,666.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3511,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3512,OTHER MUSCULOSKELETAL SYSTEM & CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$3,066.17 ",IP,"3,066.17","3,066.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3513,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$4,449.61 ",IP,"4,449.61","4,449.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3514,OTHER MUSCULOSKELETAL SYSTEM and CONNECTIVE TISSUE DIAGNOSES,,Relative Weights,"$8,785.14 ",IP,"8,785.14","8,785.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3611,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$5,861.92 ",IP,"5,861.92","5,861.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3612,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$6,759.47 ",IP,"6,759.47","6,759.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3613,SKIN GRAFT FOR SKIN and SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$10,411.18 ",IP,"10,411.18","10,411.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3614,SKIN GRAFT FOR SKIN & SUBCUTANEOUS TISSUE DIAGNOSES,,Relative Weights,"$23,051.12 ",IP,"23,051.12","23,051.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3621,MASTECTOMY PROCEDURES,,Relative Weights,"$5,733.06 ",IP,"5,733.06","5,733.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3622,MASTECTOMY PROCEDURES,,Relative Weights,"$6,783.86 ",IP,"6,783.86","6,783.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3623,MASTECTOMY PROCEDURES,,Relative Weights,"$8,730.85 ",IP,"8,730.85","8,730.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3624,MASTECTOMY PROCEDURES,,Relative Weights,"$15,662.13 ",IP,"15,662.13","15,662.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3631,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$5,772.23 ",IP,"5,772.23","5,772.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3632,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$7,919.20 ",IP,"7,919.20","7,919.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3633,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$10,641.07 ",IP,"10,641.07","10,641.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3634,BREAST PROCEDURES EXCEPT MASTECTOMY,,Relative Weights,"$13,007.96 ",IP,"13,007.96","13,007.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3641,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$3,659.27 ",IP,"3,659.27","3,659.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3642,"OTHER SKIN, SUBCUTANEOUS TISSUE & RELATED PROCEDURES",,Relative Weights,"$5,232.39 ",IP,"5,232.39","5,232.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3643,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$8,152.18 ",IP,"8,152.18","8,152.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3644,OTHER SKIN SUBCUTANEOUS TISSUE and RELATED PROCEDURES,,Relative Weights,"$16,685.79 ",IP,"16,685.79","16,685.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3801,SKIN ULCERS,,Relative Weights,"$2,950.72 ",IP,"2,950.72","2,950.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3802,SKIN ULCERS,,Relative Weights,"$3,415.64 ",IP,"3,415.64","3,415.64",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3803,SKIN ULCERS,,Relative Weights,"$4,667.13 ",IP,"4,667.13","4,667.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3804,SKIN ULCERS,,Relative Weights,"$9,197.15 ",IP,"9,197.15","9,197.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3811,MAJOR SKIN DISORDERS,,Relative Weights,"$2,135.64 ",IP,"2,135.64","2,135.64",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3812,MAJOR SKIN DISORDERS,,Relative Weights,"$3,426.98 ",IP,"3,426.98","3,426.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3813,MAJOR SKIN DISORDERS,,Relative Weights,"$6,058.47 ",IP,"6,058.47","6,058.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3814,MAJOR SKIN DISORDERS,,Relative Weights,"$15,997.51 ",IP,"15,997.51","15,997.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3821,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,708.41 ",IP,"3,708.41","3,708.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3822,MALIGNANT BREAST DISORDERS,,Relative Weights,"$3,837.96 ",IP,"3,837.96","3,837.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3823,MALIGNANT BREAST DISORDERS,,Relative Weights,"$5,221.05 ",IP,"5,221.05","5,221.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3824,MALIGNANT BREAST DISORDERS,,Relative Weights,"$8,582.75 ",IP,"8,582.75","8,582.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3831,CELLULITIS & OTHER SKIN INFECTIONS,,Relative Weights,"$2,128.08 ",IP,"2,128.08","2,128.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3832,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$2,886.11 ",IP,"2,886.11","2,886.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3833,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$4,151.00 ",IP,"4,151.00","4,151.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3834,CELLULITIS and OTHER SKIN INFECTIONS,,Relative Weights,"$8,552.16 ",IP,"8,552.16","8,552.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3841,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$2,690.94 ",IP,"2,690.94","2,690.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3842,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$3,464.09 ",IP,"3,464.09","3,464.09",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3843,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$4,737.92 ",IP,"4,737.92","4,737.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3844,CONTUSION OPEN WOUND and OTHER TRAUMA TO SKIN and SUBCUTANEOUS TISSUE,,Relative Weights,"$9,439.41 ",IP,"9,439.41","9,439.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3851,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,189.24 ",IP,"2,189.24","2,189.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3852,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$2,880.96 ",IP,"2,880.96","2,880.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3853,"OTHER SKIN, SUBCUTANEOUS TISSUE & BREAST DISORDERS",,Relative Weights,"$4,186.05 ",IP,"4,186.05","4,186.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,3854,OTHER SKIN SUBCUTANEOUS TISSUE and BREAST DISORDERS,,Relative Weights,"$8,871.05 ",IP,"8,871.05","8,871.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4011,ADRENAL PROCEDURES,,Relative Weights,"$6,855.68 ",IP,"6,855.68","6,855.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4012,ADRENAL PROCEDURES,,Relative Weights,"$10,778.52 ",IP,"10,778.52","10,778.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4013,ADRENAL PROCEDURES,,Relative Weights,"$13,300.04 ",IP,"13,300.04","13,300.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4014,ADRENAL PROCEDURES,,Relative Weights,"$24,027.70 ",IP,"24,027.70","24,027.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4031,PROCEDURES FOR OBESITY,,Relative Weights,"$5,110.06 ",IP,"5,110.06","5,110.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4032,PROCEDURES FOR OBESITY,,Relative Weights,"$6,108.30 ",IP,"6,108.30","6,108.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4033,PROCEDURES FOR OBESITY,,Relative Weights,"$9,074.13 ",IP,"9,074.13","9,074.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4034,PROCEDURES FOR OBESITY,,Relative Weights,"$26,392.19 ",IP,"26,392.19","26,392.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4041,"THYROID, PARATHYROID & THYROGLOSSAL PROCEDURES",,Relative Weights,"$4,728.64 ",IP,"4,728.64","4,728.64",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4042,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4043,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$10,989.85 ",IP,"10,989.85","10,989.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4044,THYROID PARATHYROID and THYROGLOSSAL PROCEDURES,,Relative Weights,"$24,206.39 ",IP,"24,206.39","24,206.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4051,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$7,505.82 ",IP,"7,505.82","7,505.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4052,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$8,475.19 ",IP,"8,475.19","8,475.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4053,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$12,612.79 ",IP,"12,612.79","12,612.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4054,OTHER PROCEDURES FOR ENDOCRINE NUTRITIONAL and METABOLIC DISORDERS,,Relative Weights,"$26,164.03 ",IP,"26,164.03","26,164.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4201,DIABETES,,Relative Weights,"$2,259.68 ",IP,"2,259.68","2,259.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4202,DIABETES,,Relative Weights,"$2,723.24 ",IP,"2,723.24","2,723.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4203,DIABETES,,Relative Weights,"$3,776.79 ",IP,"3,776.79","3,776.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4204,DIABETES,,Relative Weights,"$8,028.82 ",IP,"8,028.82","8,028.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4211,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$2,343.53 ",IP,"2,343.53","2,343.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4212,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$3,329.74 ",IP,"3,329.74","3,329.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4213,"MALNUTRITION, FAILURE TO THRIVE & OTHER NUTRITIONAL DISORDERS",,Relative Weights,"$5,181.88 ",IP,"5,181.88","5,181.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4214,MALNUTRITION FAILURE TO THRIVE and OTHER NUTRITIONAL DISORDERS,,Relative Weights,"$10,295.72 ",IP,"10,295.72","10,295.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4221,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$1,870.01 ",IP,"1,870.01","1,870.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4222,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$2,609.84 ",IP,"2,609.84","2,609.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4223,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$3,459.28 ",IP,"3,459.28","3,459.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4224,HYPOVOLEMIA and RELATED ELECTROLYTE DISORDERS,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4231,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,529.29 ",IP,"5,529.29","5,529.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4232,INBORN ERRORS OF METABOLISM,,Relative Weights,"$5,948.85 ",IP,"5,948.85","5,948.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4233,INBORN ERRORS OF METABOLISM,,Relative Weights,"$8,447.01 ",IP,"8,447.01","8,447.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4234,INBORN ERRORS OF METABOLISM,,Relative Weights,"$27,194.91 ",IP,"27,194.91","27,194.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4241,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$2,869.62 ",IP,"2,869.62","2,869.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4242,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$3,662.02 ",IP,"3,662.02","3,662.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4243,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4244,OTHER ENDOCRINE DISORDERS,,Relative Weights,"$10,807.73 ",IP,"10,807.73","10,807.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4251,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,221.89 ",IP,"2,221.89","2,221.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4252,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$2,908.79 ",IP,"2,908.79","2,908.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4253,OTHER NON-HYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$3,943.11 ",IP,"3,943.11","3,943.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4254,OTHER NONHYPOVOLEMIC ELECTROLYTE DISORDERS,,Relative Weights,"$7,662.17 ",IP,"7,662.17","7,662.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4261,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,409.16 ",IP,"2,409.16","2,409.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4262,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$2,941.78 ",IP,"2,941.78","2,941.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4263,NON-HYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$4,191.21 ",IP,"4,191.21","4,191.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4264,NONHYPOVOLEMIC SODIUM DISORDERS,,Relative Weights,"$8,224.69 ",IP,"8,224.69","8,224.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4271,THYROID DISORDERS,,Relative Weights,"$2,411.91 ",IP,"2,411.91","2,411.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4272,THYROID DISORDERS,,Relative Weights,"$3,208.44 ",IP,"3,208.44","3,208.44",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4273,THYROID DISORDERS,,Relative Weights,"$4,621.77 ",IP,"4,621.77","4,621.77",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4274,THYROID DISORDERS,,Relative Weights,"$9,834.92 ",IP,"9,834.92","9,834.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4401,KIDNEY TRANSPLANT,,Relative Weights,"$26,376.39 ",IP,"26,376.39","26,376.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4402,KIDNEY TRANSPLANT,,Relative Weights,"$28,441.58 ",IP,"28,441.58","28,441.58",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4403,KIDNEY TRANSPLANT,,Relative Weights,"$31,863.75 ",IP,"31,863.75","31,863.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4404,KIDNEY TRANSPLANT,,Relative Weights,"$48,433.40 ",IP,"48,433.40","48,433.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4411,MAJOR BLADDER PROCEDURES,,Relative Weights,"$7,124.74 ",IP,"7,124.74","7,124.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4412,MAJOR BLADDER PROCEDURES,,Relative Weights,"$11,337.94 ",IP,"11,337.94","11,337.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4413,MAJOR BLADDER PROCEDURES,,Relative Weights,"$14,853.23 ",IP,"14,853.23","14,853.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4414,MAJOR BLADDER PROCEDURES,,Relative Weights,"$32,299.47 ",IP,"32,299.47","32,299.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4421,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,007.22 ",IP,"7,007.22","7,007.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4422,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$7,784.16 ",IP,"7,784.16","7,784.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4423,KIDNEY & URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$11,551.33 ",IP,"11,551.33","11,551.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4424,KIDNEY and URINARY TRACT PROCEDURES FOR MALIGNANCY,,Relative Weights,"$20,973.56 ",IP,"20,973.56","20,973.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4431,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$5,745.77 ",IP,"5,745.77","5,745.77",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4432,KIDNEY and URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$6,928.19 ",IP,"6,928.19","6,928.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4433,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$10,300.53 ",IP,"10,300.53","10,300.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4434,KIDNEY & URINARY TRACT PROCEDURES FOR NONMALIGNANCY,,Relative Weights,"$21,259.80 ",IP,"21,259.80","21,259.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4441,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$6,643.67 ",IP,"6,643.67","6,643.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4442,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$8,351.49 ",IP,"8,351.49","8,351.49",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4443,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$12,840.62 ",IP,"12,840.62","12,840.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4444,RENAL DIALYSIS ACCESS DEVICE AND VESSEL REPAIR,,Relative Weights,"$25,251.70 ",IP,"25,251.70","25,251.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4451,OTHER BLADDER PROCEDURES,,Relative Weights,"$4,867.46 ",IP,"4,867.46","4,867.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4452,OTHER BLADDER PROCEDURES,,Relative Weights,"$6,607.93 ",IP,"6,607.93","6,607.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4453,OTHER BLADDER PROCEDURES,,Relative Weights,"$8,634.63 ",IP,"8,634.63","8,634.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4454,OTHER BLADDER PROCEDURES,,Relative Weights,"$17,913.22 ",IP,"17,913.22","17,913.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4461,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$4,096.37 ",IP,"4,096.37","4,096.37",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4462,URETHRAL & TRANSURETHRAL PROCEDURES,,Relative Weights,"$5,093.91 ",IP,"5,093.91","5,093.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4463,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$7,454.97 ",IP,"7,454.97","7,454.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4464,URETHRAL and TRANSURETHRAL PROCEDURES,,Relative Weights,"$15,279.67 ",IP,"15,279.67","15,279.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4471,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$6,383.54 ",IP,"6,383.54","6,383.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4472,"OTHER KIDNEY, URINARY TRACT & RELATED PROCEDURES",,Relative Weights,"$7,988.27 ",IP,"7,988.27","7,988.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4473,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$11,578.48 ",IP,"11,578.48","11,578.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4474,OTHER KIDNEY URINARY TRACT and RELATED PROCEDURES,,Relative Weights,"$26,335.15 ",IP,"26,335.15","26,335.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4611,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,213.89 ",IP,"4,213.89","4,213.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4612,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$4,354.09 ",IP,"4,354.09","4,354.09",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4613,KIDNEY and URINARY TRACT MALIGNANCY,,Relative Weights,"$5,833.40 ",IP,"5,833.40","5,833.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4614,KIDNEY & URINARY TRACT MALIGNANCY,,Relative Weights,"$10,495.71 ",IP,"10,495.71","10,495.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4621,NEPHRITIS and NEPHROSIS,,Relative Weights,"$2,361.40 ",IP,"2,361.40","2,361.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4622,NEPHRITIS and NEPHROSIS,,Relative Weights,"$3,007.07 ",IP,"3,007.07","3,007.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4623,NEPHRITIS and NEPHROSIS,,Relative Weights,"$5,343.04 ",IP,"5,343.04","5,343.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4624,NEPHRITIS and NEPHROSIS,,Relative Weights,"$14,645.34 ",IP,"14,645.34","14,645.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4631,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,386.48 ",IP,"2,386.48","2,386.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4632,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$2,925.29 ",IP,"2,925.29","2,925.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4633,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$3,755.49 ",IP,"3,755.49","3,755.49",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4634,KIDNEY and URINARY TRACT INFECTIONS,,Relative Weights,"$6,746.75 ",IP,"6,746.75","6,746.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4651,URINARY STONES & ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$2,676.16 ",IP,"2,676.16","2,676.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4652,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$3,212.22 ",IP,"3,212.22","3,212.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4653,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$4,385.36 ",IP,"4,385.36","4,385.36",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4654,URINARY STONES and ACQUIRED UPPER URINARY TRACT OBSTRUCTION,,Relative Weights,"$8,949.40 ",IP,"8,949.40","8,949.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4661,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$2,602.62 ",IP,"2,602.62","2,602.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4662,"MALFUNCTION, REACTION, COMPLIC OF GENITOURINARY DEVICE OR PROC",,Relative Weights,"$3,336.61 ",IP,"3,336.61","3,336.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4663,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$4,821.07 ",IP,"4,821.07","4,821.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4664,MALFUNCTION REACTION COMPLIC OF GENITOURINARY DEVICE OR PROC,,Relative Weights,"$8,281.73 ",IP,"8,281.73","8,281.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4681,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$2,645.58 ",IP,"2,645.58","2,645.58",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4682,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$3,341.08 ",IP,"3,341.08","3,341.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4683,"OTHER KIDNEY & URINARY TRACT DIAGNOSES, SIGNS & SYMPTOMS",,Relative Weights,"$4,559.92 ",IP,"4,559.92","4,559.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4684,OTHER KIDNEY and URINARY TRACT DIAGNOSES SIGNS and SYMPTOMS,,Relative Weights,"$9,588.20 ",IP,"9,588.20","9,588.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4691,ACUTE KIDNEY INJURY,,Relative Weights,"$2,379.95 ",IP,"2,379.95","2,379.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4692,ACUTE KIDNEY INJURY,,Relative Weights,"$3,050.71 ",IP,"3,050.71","3,050.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4693,ACUTE KIDNEY INJURY,,Relative Weights,"$4,563.35 ",IP,"4,563.35","4,563.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4694,ACUTE KIDNEY INJURY,,Relative Weights,"$9,568.95 ",IP,"9,568.95","9,568.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4701,CHRONIC KIDNEY DISEASE,,Relative Weights,"$2,503.66 ",IP,"2,503.66","2,503.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4702,CHRONIC KIDNEY DISEASE,,Relative Weights,"$3,283.35 ",IP,"3,283.35","3,283.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4703,CHRONIC KIDNEY DISEASE,,Relative Weights,"$4,530.02 ",IP,"4,530.02","4,530.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4704,CHRONIC KIDNEY DISEASE,,Relative Weights,"$8,193.42 ",IP,"8,193.42","8,193.42",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4801,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,131.66 ",IP,"6,131.66","6,131.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4802,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$6,485.60 ",IP,"6,485.60","6,485.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4803,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$10,188.85 ",IP,"10,188.85","10,188.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4804,MAJOR MALE PELVIC PROCEDURES,,Relative Weights,"$21,900.66 ",IP,"21,900.66","21,900.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4821,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,027.30 ",IP,"4,027.30","4,027.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4822,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$4,459.58 ",IP,"4,459.58","4,459.58",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4823,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$7,759.08 ",IP,"7,759.08","7,759.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4824,TRANSURETHRAL PROSTATECTOMY,,Relative Weights,"$15,069.03 ",IP,"15,069.03","15,069.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4831,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$5,523.10 ",IP,"5,523.10","5,523.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4832,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$6,593.84 ",IP,"6,593.84","6,593.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4833,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$8,503.71 ",IP,"8,503.71","8,503.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4834,PENIS TESTES and SCROTAL PROCEDURES,,Relative Weights,"$16,764.14 ",IP,"16,764.14","16,764.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4841,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,414.47 ",IP,"6,414.47","6,414.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4842,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$6,893.48 ",IP,"6,893.48","6,893.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4843,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$7,922.98 ",IP,"7,922.98","7,922.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,4844,OTHER MALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$22,148.41 ",IP,"22,148.41","22,148.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5001,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,471.31 ",IP,"3,471.31","3,471.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5002,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$3,960.98 ",IP,"3,960.98","3,960.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5003,"MALIGNANCY, MALE REPRODUCTIVE SYSTEM",,Relative Weights,"$5,381.18 ",IP,"5,381.18","5,381.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5004,MALIGNANCY MALE REPRODUCTIVE SYSTEM,,Relative Weights,"$8,653.88 ",IP,"8,653.88","8,653.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5011,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,269.65 ",IP,"2,269.65","2,269.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5012,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$2,988.52 ",IP,"2,988.52","2,988.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5013,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$4,126.95 ",IP,"4,126.95","4,126.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5014,MALE REPRODUCTIVE SYSTEM DIAGNOSES EXCEPT MALIGNANCY,,Relative Weights,"$8,519.52 ",IP,"8,519.52","8,519.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5101,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$6,667.03 ",IP,"6,667.03","6,667.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5102,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$7,636.06 ",IP,"7,636.06","7,636.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5103,"PELVIC EVISCERATION, RADICAL HYSTERECTOMY & OTHER RADICAL GYN PROCS",,Relative Weights,"$12,159.55 ",IP,"12,159.55","12,159.55",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5104,PELVIC EVISCERATION RADICAL HYSTERECTOMY and OTHER RADICAL GYN PROCS,,Relative Weights,"$22,308.54 ",IP,"22,308.54","22,308.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5111,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$6,477.69 ",IP,"6,477.69","6,477.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5112,UTERINE and ADNEXA PROCEDURES FOR OVARIAN and ADNEXAL MALIGNANCY,,Relative Weights,"$7,830.89 ",IP,"7,830.89","7,830.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5113,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$10,746.90 ",IP,"10,746.90","10,746.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5114,UTERINE & ADNEXA PROCEDURES FOR OVARIAN & ADNEXAL MALIGNANCY,,Relative Weights,"$23,120.88 ",IP,"23,120.88","23,120.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5121,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$6,341.62 ",IP,"6,341.62","6,341.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5122,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$7,038.84 ",IP,"7,038.84","7,038.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5123,UTERINE and ADNEXA PROCEDURES FOR NONOVARIAN and NONADNEXAL MALIG,,Relative Weights,"$9,937.66 ",IP,"9,937.66","9,937.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5124,UTERINE & ADNEXA PROCEDURES FOR NON-OVARIAN & NON-ADNEXAL MALIG,,Relative Weights,"$20,453.99 ",IP,"20,453.99","20,453.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5131,UTERINE & ADNEXA PROCEDURES FOR NON-MALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$4,384.67 ",IP,"4,384.67","4,384.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5132,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$5,107.31 ",IP,"5,107.31","5,107.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5133,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$8,107.86 ",IP,"8,107.86","8,107.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5134,UTERINE and ADNEXA PROCEDURES FOR NONMALIGNANCY EXCEPT LEIOMYOMA,,Relative Weights,"$16,632.53 ",IP,"16,632.53","16,632.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5141,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$3,945.51 ",IP,"3,945.51","3,945.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5142,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$5,893.19 ",IP,"5,893.19","5,893.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5143,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$10,581.96 ",IP,"10,581.96","10,581.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5144,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,,Relative Weights,"$22,849.41 ",IP,"22,849.41","22,849.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5171,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$3,258.61 ",IP,"3,258.61","3,258.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5172,DILATION & CURETTAGE FOR NON-OBSTETRIC DIAGNOSES,,Relative Weights,"$4,494.28 ",IP,"4,494.28","4,494.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5173,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$6,942.62 ",IP,"6,942.62","6,942.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5174,DILATION and CURETTAGE FOR NONOBSTETRIC DIAGNOSES,,Relative Weights,"$14,767.33 ",IP,"14,767.33","14,767.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5181,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$4,123.51 ",IP,"4,123.51","4,123.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5182,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$5,436.16 ",IP,"5,436.16","5,436.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5183,OTHER FEMALE REPRODUCTIVE SYSTEM & RELATED PROCEDURES,,Relative Weights,"$9,420.16 ",IP,"9,420.16","9,420.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5184,OTHER FEMALE REPRODUCTIVE SYSTEM and RELATED PROCEDURES,,Relative Weights,"$21,115.47 ",IP,"21,115.47","21,115.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5191,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,160.33 ",IP,"3,160.33","3,160.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5192,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$3,849.30 ",IP,"3,849.30","3,849.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5193,UTERINE & ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$7,527.81 ",IP,"7,527.81","7,527.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5194,UTERINE and ADNEXA PROCEDURES FOR LEIOMYOMA,,Relative Weights,"$15,622.96 ",IP,"15,622.96","15,622.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5301,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,382.31 ",IP,"3,382.31","3,382.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5302,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$3,815.97 ",IP,"3,815.97","3,815.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5303,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$5,327.23 ",IP,"5,327.23","5,327.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5304,FEMALE REPRODUCTIVE SYSTEM MALIGNANCY,,Relative Weights,"$9,039.08 ",IP,"9,039.08","9,039.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5311,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,096.46 ",IP,"2,096.46","2,096.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5312,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$2,868.93 ",IP,"2,868.93","2,868.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5313,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$4,503.56 ",IP,"4,503.56","4,503.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5314,FEMALE REPRODUCTIVE SYSTEM INFECTIONS,,Relative Weights,"$9,958.97 ",IP,"9,958.97","9,958.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5321,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,302.29 ",IP,"2,302.29","2,302.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5322,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$2,696.78 ",IP,"2,696.78","2,696.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5323,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$4,143.44 ",IP,"4,143.44","4,143.44",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5324,MENSTRUAL and OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS,,Relative Weights,"$9,044.24 ",IP,"9,044.24","9,044.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5401,CESAREAN DELIVERY,,Relative Weights,"$2,493.69 ",IP,"2,493.69","2,493.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5402,CESAREAN DELIVERY,,Relative Weights,"$2,909.48 ",IP,"2,909.48","2,909.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5403,CESAREAN DELIVERY,,Relative Weights,"$4,140.35 ",IP,"4,140.35","4,140.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5404,CESAREAN DELIVERY,,Relative Weights,"$8,525.02 ",IP,"8,525.02","8,525.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5411,VAGINAL DELIVERY W STERILIZATION &/OR D&C,,Relative Weights,"$2,683.03 ",IP,"2,683.03","2,683.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5412,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$2,694.03 ",IP,"2,694.03","2,694.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5413,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$3,800.85 ",IP,"3,800.85","3,800.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5414,VAGINAL DELIVERY W STERILIZATION andOR DandC,,Relative Weights,"$9,356.59 ",IP,"9,356.59","9,356.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5421,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION &/OR D&C,,Relative Weights,"$1,729.81 ",IP,"1,729.81","1,729.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5422,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$1,962.10 ",IP,"1,962.10","1,962.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5423,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$2,979.24 ",IP,"2,979.24","2,979.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5424,VAGINAL DELIVERY W COMPLICATING PROCEDURES EXC STERILIZATION andOR DandC,,Relative Weights,"$11,346.53 ",IP,"11,346.53","11,346.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5441,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$1,946.30 ",IP,"1,946.30","1,946.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5442,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$2,595.06 ",IP,"2,595.06","2,595.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5443,"D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES",,Relative Weights,"$3,856.51 ",IP,"3,856.51","3,856.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5444,DandC ASPIRATION CURETTAGE OR HYSTEROTOMY FOR OBSTETRIC DIAGNOSES,,Relative Weights,"$14,310.30 ",IP,"14,310.30","14,310.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5451,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$2,785.09 ",IP,"2,785.09","2,785.09",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5452,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,114.63 ",IP,"3,114.63","3,114.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5453,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$3,214.96 ",IP,"3,214.96","3,214.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5454,ECTOPIC PREGNANCY PROCEDURE,,Relative Weights,"$4,812.48 ",IP,"4,812.48","4,812.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5461,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$2,385.45 ",IP,"2,385.45","2,385.45",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5462,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$4,587.41 ",IP,"4,587.41","4,587.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5463,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$5,857.79 ",IP,"5,857.79","5,857.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5464,OTHER OR PROC FOR OBSTETRIC DIAGNOSES EXCEPT DELIVERY DIAGNOSES,,Relative Weights,"$11,895.30 ",IP,"11,895.30","11,895.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5601,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,539.10 ",IP,"1,539.10","1,539.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5602,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$1,659.37 ",IP,"1,659.37","1,659.37",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5603,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$2,337.34 ",IP,"2,337.34","2,337.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5604,VAGINAL DELIVERY,VAGINAL DELIVERY,Relative Weights,"$4,292.23 ",IP,"4,292.23","4,292.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5611,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,236.71 ",IP,"1,236.71","1,236.71",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5612,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$1,778.26 ",IP,"1,778.26","1,778.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5613,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$2,747.29 ",IP,"2,747.29","2,747.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5614,POSTPARTUM and POST ABORTION DIAGNOSES WO PROCEDURE,,Relative Weights,"$5,898.34 ",IP,"5,898.34","5,898.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5631,PRETERM LABOR,,Relative Weights,"$1,387.56 ",IP,"1,387.56","1,387.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5632,PRETERM LABOR,,Relative Weights,"$1,719.85 ",IP,"1,719.85","1,719.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5633,PRETERM LABOR,,Relative Weights,"$2,634.92 ",IP,"2,634.92","2,634.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5634,PRETERM LABOR,,Relative Weights,"$4,637.23 ",IP,"4,637.23","4,637.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5641,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$1,463.85 ",IP,"1,463.85","1,463.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5642,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$1,520.55 ",IP,"1,520.55","1,520.55",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5643,"ABORTION W/O D&C, ASPIRATION CURETTAGE OR HYSTEROTOMY",,Relative Weights,"$2,435.62 ",IP,"2,435.62","2,435.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5644,ABORTION WO DandC ASPIRATION CURETTAGE OR HYSTEROTOMY,,Relative Weights,"$3,935.55 ",IP,"3,935.55","3,935.55",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5651,FALSE LABOR,FALSE LABOR,Relative Weights,$992.39 ,IP,992.39,992.39,,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5652,FALSE LABOR,FALSE LABOR,Relative Weights,"$1,254.23 ",IP,"1,254.23","1,254.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5653,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5654,FALSE LABOR,FALSE LABOR,Relative Weights,"$2,123.61 ",IP,"2,123.61","2,123.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5661,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,462.82 ",IP,"1,462.82","1,462.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5662,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$1,906.44 ",IP,"1,906.44","1,906.44",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5663,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$2,718.08 ",IP,"2,718.08","2,718.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5664,OTHER ANTEPARTUM DIAGNOSES,,Relative Weights,"$5,715.19 ",IP,"5,715.19","5,715.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5801,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$1,625.35 ",IP,"1,625.35","1,625.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5802,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$2,301.61 ",IP,"2,301.61","2,301.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5803,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$3,477.84 ",IP,"3,477.84","3,477.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5804,NEONATE TRANSFERRED 5 DAYS OLD NOT BORN HERE,,Relative Weights,"$6,537.48 ",IP,"6,537.48","6,537.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5811,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,$559.42 ,IP,559.42,559.42,,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5812,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,$716.80 ,IP,716.8,716.8,,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5813,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,"$1,204.41 ",IP,"1,204.41","1,204.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5814,NEONATE TRANSFERRED 5 DAYS OLD BORN HERE,,Relative Weights,"$2,109.52 ",IP,"2,109.52","2,109.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5831,NEONATE W ECMO,,Relative Weights,"$87,271.04 ",IP,"87,271.04","87,271.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5832,NEONATE W ECMO,,Relative Weights,"$87,459.00 ",IP,"87,459.00","87,459.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5833,NEONATE W ECMO,,Relative Weights,"$148,358.12 ",IP,"148,358.12","148,358.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5834,NEONATE W ECMO,,Relative Weights,"$163,193.83 ",IP,"163,193.83","163,193.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5881,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$67,852.39 ",IP,"67,852.39","67,852.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5882,NEONATE BWT <1500G W MAJOR PROCEDURE,,Relative Weights,"$75,391.54 ",IP,"75,391.54","75,391.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5883,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$83,636.16 ",IP,"83,636.16","83,636.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5884,NEONATE BWT 1500G W MAJOR PROCEDURE,,Relative Weights,"$133,619.66 ",IP,"133,619.66","133,619.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5891,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$98,896.59 ",IP,"98,896.59","98,896.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5892,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$69,370.87 ",IP,"69,370.87","69,370.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5893,NEONATE BWT 500G OR GA 24 WEEKS,,Relative Weights,"$63,064.65 ",IP,"63,064.65","63,064.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5894,NEONATE BWT <500G OR GA <24 WEEKS,,Relative Weights,"$11,889.12 ",IP,"11,889.12","11,889.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5911,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$57,344.65 ",IP,"57,344.65","57,344.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5912,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$79,559.04 ",IP,"79,559.04","79,559.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5913,NEONATE BIRTHWT 500749G WO MAJOR PROCEDURE,,Relative Weights,"$85,488.65 ",IP,"85,488.65","85,488.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5914,NEONATE BIRTHWT 500-749G W/O MAJOR PROCEDURE,,Relative Weights,"$110,417.00 ",IP,"110,417.00","110,417.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5931,NEONATE BIRTHWT 750-999G W/O MAJOR PROCEDURE,,Relative Weights,"$37,781.34 ",IP,"37,781.34","37,781.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5932,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$59,330.12 ",IP,"59,330.12","59,330.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5933,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$71,323.01 ",IP,"71,323.01","71,323.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,5934,NEONATE BIRTHWT 750999G WO MAJOR PROCEDURE,,Relative Weights,"$96,423.52 ",IP,"96,423.52","96,423.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6021,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$36,367.31 ",IP,"36,367.31","36,367.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6022,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$43,081.42 ",IP,"43,081.42","43,081.42",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6023,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$56,708.94 ",IP,"56,708.94","56,708.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6024,NEONATE BWT 10001249G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$82,218.02 ",IP,"82,218.02","82,218.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6031,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$21,131.62 ",IP,"21,131.62","21,131.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6032,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$31,760.66 ",IP,"31,760.66","31,760.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6033,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,733.18 ",IP,"45,733.18","45,733.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6034,NEONATE BIRTHWT 10001249G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$71,521.63 ",IP,"71,521.63","71,521.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6071,NEONATE BWT 1250-1499G W RESP DIST SYND/OTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$24,973.02 ",IP,"24,973.02","24,973.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6072,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$31,699.15 ",IP,"31,699.15","31,699.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6073,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$41,632.01 ",IP,"41,632.01","41,632.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6074,NEONATE BWT 12501499G W RESP DIST SYNDOTH MAJ RESP OR MAJ ANOM,,Relative Weights,"$64,492.07 ",IP,"64,492.07","64,492.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6081,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$16,607.44 ",IP,"16,607.44","16,607.44",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6082,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$23,967.23 ",IP,"23,967.23","23,967.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6083,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$34,646.09 ",IP,"34,646.09","34,646.09",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6084,NEONATE BWT 12501499G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$60,788.81 ",IP,"60,788.81","60,788.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6091,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$25,499.11 ",IP,"25,499.11","25,499.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6092,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$27,431.32 ",IP,"27,431.32","27,431.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6093,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$47,002.54 ",IP,"47,002.54","47,002.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6094,NEONATE BWT 15002499G W MAJOR PROCEDURE,,Relative Weights,"$99,687.62 ",IP,"99,687.62","99,687.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6111,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$12,585.30 ",IP,"12,585.30","12,585.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6112,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$19,393.91 ",IP,"19,393.91","19,393.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6113,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$32,347.92 ",IP,"32,347.92","32,347.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6114,NEONATE BIRTHWT 15001999G W MAJOR ANOMALY,,Relative Weights,"$58,174.51 ",IP,"58,174.51","58,174.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6121,NEONATE BWT 1500-1999G W RESP DIST SYND/OTH MAJ RESP COND,,Relative Weights,"$16,224.65 ",IP,"16,224.65","16,224.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6122,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$21,637.79 ",IP,"21,637.79","21,637.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6123,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$29,186.22 ",IP,"29,186.22","29,186.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6124,NEONATE BWT 15001999G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$42,407.23 ",IP,"42,407.23","42,407.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6131,NEONATE BIRTHWT 1500-1999G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,196.61 ",IP,"13,196.61","13,196.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6132,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$21,189.35 ",IP,"21,189.35","21,189.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6133,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$27,656.40 ",IP,"27,656.40","27,656.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6134,NEONATE BIRTHWT 15001999G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$47,731.03 ",IP,"47,731.03","47,731.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6141,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,925.34 ",IP,"8,925.34","8,925.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6142,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$15,030.54 ",IP,"15,030.54","15,030.54",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6143,NEONATE BWT 1500-1999G W OR W/O OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,580.55 ",IP,"25,580.55","25,580.55",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6144,NEONATE BWT 15001999G W OR WO OTHER SIGNIFICANT CONDITION,,Relative Weights,"$45,341.79 ",IP,"45,341.79","45,341.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6211,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$6,929.91 ",IP,"6,929.91","6,929.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6212,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$14,367.69 ",IP,"14,367.69","14,367.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6213,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$26,320.72 ",IP,"26,320.72","26,320.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6214,NEONATE BWT 20002499G W MAJOR ANOMALY,,Relative Weights,"$49,514.79 ",IP,"49,514.79","49,514.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6221,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$10,129.06 ",IP,"10,129.06","10,129.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6222,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$13,681.47 ",IP,"13,681.47","13,681.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6223,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$17,417.03 ",IP,"17,417.03","17,417.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6224,NEONATE BWT 20002499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$32,501.52 ",IP,"32,501.52","32,501.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6231,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$7,947.73 ",IP,"7,947.73","7,947.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6232,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$11,704.59 ",IP,"11,704.59","11,704.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6233,NEONATE BWT 20002499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$18,604.26 ",IP,"18,604.26","18,604.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6234,NEONATE BWT 2000-2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$29,470.40 ",IP,"29,470.40","29,470.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6251,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$8,481.72 ",IP,"8,481.72","8,481.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6252,NEONATE BWT 20002499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$12,056.81 ",IP,"12,056.81","12,056.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6253,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$17,253.12 ",IP,"17,253.12","17,253.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6254,NEONATE BWT 2000-2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$25,500.83 ",IP,"25,500.83","25,500.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6261,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,026.75 ",IP,"1,026.75","1,026.75",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6262,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$1,832.56 ",IP,"1,832.56","1,832.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6263,NEONATE BWT 20002499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$5,129.99 ",IP,"5,129.99","5,129.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6264,"NEONATE BWT 2000-2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$14,511.67 ",IP,"14,511.67","14,511.67",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6301,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$14,642.59 ",IP,"14,642.59","14,642.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6302,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$26,499.41 ",IP,"26,499.41","26,499.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6303,NEONATE BIRTHWT 2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$44,508.84 ",IP,"44,508.84","44,508.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6304,NEONATE BIRTHWT >2499G W MAJOR CARDIOVASCULAR PROCEDURE,,Relative Weights,"$79,154.59 ",IP,"79,154.59","79,154.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6311,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$11,884.65 ",IP,"11,884.65","11,884.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6312,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$19,077.77 ",IP,"19,077.77","19,077.77",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6313,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$33,764.00 ",IP,"33,764.00","33,764.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6314,NEONATE BIRTHWT 2499G W OTHER MAJOR PROCEDURE,,Relative Weights,"$74,464.79 ",IP,"74,464.79","74,464.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6331,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$2,688.87 ",IP,"2,688.87","2,688.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6332,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$7,851.51 ",IP,"7,851.51","7,851.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6333,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$17,713.92 ",IP,"17,713.92","17,713.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6334,NEONATE BIRTHWT 2499G W MAJOR ANOMALY,,Relative Weights,"$44,843.19 ",IP,"44,843.19","44,843.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6341,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$4,461.64 ",IP,"4,461.64","4,461.64",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6342,"NEONATE, BIRTHWT >2499G W RESP DIST SYND/OTH MAJ RESP COND",,Relative Weights,"$7,881.41 ",IP,"7,881.41","7,881.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6343,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$11,444.81 ",IP,"11,444.81","11,444.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6344,NEONATE BIRTHWT 2499G W RESP DIST SYNDOTH MAJ RESP COND,,Relative Weights,"$28,806.17 ",IP,"28,806.17","28,806.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6361,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$4,375.39 ",IP,"4,375.39","4,375.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6362,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$6,615.83 ",IP,"6,615.83","6,615.83",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6363,NEONATE BIRTHWT >2499G W CONGENITAL/PERINATAL INFECTION,,Relative Weights,"$13,140.60 ",IP,"13,140.60","13,140.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6364,NEONATE BIRTHWT 2499G W CONGENITALPERINATAL INFECTION,,Relative Weights,"$22,289.30 ",IP,"22,289.30","22,289.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6391,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$4,122.14 ",IP,"4,122.14","4,122.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6392,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$7,440.19 ",IP,"7,440.19","7,440.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6393,NEONATE BIRTHWT >2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$11,681.22 ",IP,"11,681.22","11,681.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6394,NEONATE BIRTHWT 2499G W OTHER SIGNIFICANT CONDITION,,Relative Weights,"$20,735.08 ",IP,"20,735.08","20,735.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6401,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$571.11 ,IP,571.11,571.11,,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6402,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,$900.64 ,IP,900.64,900.64,,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6403,"NEONATE BIRTHWT >2499G, NORMAL NEWBORN OR NEONATE W OTHER PROBLEM",,Relative Weights,"$2,228.41 ",IP,"2,228.41","2,228.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6404,NEONATE BIRTHWT 2499G NORMAL NEWBORN OR NEONATE W OTHER PROBLEM,,Relative Weights,"$13,890.74 ",IP,"13,890.74","13,890.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6501,SPLENECTOMY,,Relative Weights,"$6,304.16 ",IP,"6,304.16","6,304.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6502,SPLENECTOMY,,Relative Weights,"$8,491.69 ",IP,"8,491.69","8,491.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6503,SPLENECTOMY,,Relative Weights,"$13,332.00 ",IP,"13,332.00","13,332.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6504,SPLENECTOMY,,Relative Weights,"$23,483.06 ",IP,"23,483.06","23,483.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6511,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$5,293.90 ",IP,"5,293.90","5,293.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6512,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$7,236.76 ",IP,"7,236.76","7,236.76",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6513,OTHER PROCEDURES OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$10,916.31 ",IP,"10,916.31","10,916.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6514,OTHER PROCEDURES OF BLOOD & BLOOD-FORMING ORGANS,,Relative Weights,"$33,538.24 ",IP,"33,538.24","33,538.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6601,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$3,747.59 ",IP,"3,747.59","3,747.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6602,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$4,287.77 ",IP,"4,287.77","4,287.77",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6603,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$6,366.70 ",IP,"6,366.70","6,366.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6604,MAJOR HEMATOLOGICIMMUNOLOGIC DIAG EXC SICKLE CELL CRISIS and COAGUL,,Relative Weights,"$16,194.41 ",IP,"16,194.41","16,194.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6611,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$3,902.56 ",IP,"3,902.56","3,902.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6612,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$5,668.11 ",IP,"5,668.11","5,668.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6613,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$9,739.74 ",IP,"9,739.74","9,739.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6614,COAGULATION and PLATELET DISORDERS,,Relative Weights,"$15,545.30 ",IP,"15,545.30","15,545.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6621,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$2,821.17 ",IP,"2,821.17","2,821.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6622,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$3,681.27 ",IP,"3,681.27","3,681.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6623,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$5,206.96 ",IP,"5,206.96","5,206.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6624,SICKLE CELL ANEMIA CRISIS,,Relative Weights,"$10,694.33 ",IP,"10,694.33","10,694.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6631,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$2,701.59 ",IP,"2,701.59","2,701.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6632,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$3,327.33 ",IP,"3,327.33","3,327.33",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6633,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$4,391.20 ",IP,"4,391.20","4,391.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6634,OTHER ANEMIA and DISORDERS OF BLOOD and BLOODFORMING ORGANS,,Relative Weights,"$8,007.52 ",IP,"8,007.52","8,007.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6801,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,740.52 ",IP,"7,740.52","7,740.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6802,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$10,236.62 ",IP,"10,236.62","10,236.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6803,MAJOR OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$16,199.56 ",IP,"16,199.56","16,199.56",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6804,MAJOR O.R. PROCEDURES FOR LYMPHATIC/HEMATOPOIETIC/OTHER NEOPLASMS,,Relative Weights,"$34,974.94 ",IP,"34,974.94","34,974.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6811,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$6,220.66 ",IP,"6,220.66","6,220.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6812,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$7,805.46 ",IP,"7,805.46","7,805.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6813,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$13,731.30 ",IP,"13,731.30","13,731.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6814,OTHER OR PROCEDURES FOR LYMPHATICHEMATOPOIETICOTHER NEOPLASMS,,Relative Weights,"$32,311.50 ",IP,"32,311.50","32,311.50",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6901,ACUTE LEUKEMIA,,Relative Weights,"$8,376.23 ",IP,"8,376.23","8,376.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6902,ACUTE LEUKEMIA,,Relative Weights,"$11,965.06 ",IP,"11,965.06","11,965.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6903,ACUTE LEUKEMIA,,Relative Weights,"$18,264.07 ",IP,"18,264.07","18,264.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6904,ACUTE LEUKEMIA,,Relative Weights,"$33,495.63 ",IP,"33,495.63","33,495.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6911,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$6,184.92 ",IP,"6,184.92","6,184.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6912,"LYMPHOMA, MYELOMA & NON-ACUTE LEUKEMIA",,Relative Weights,"$6,251.93 ",IP,"6,251.93","6,251.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6913,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$9,090.97 ",IP,"9,090.97","9,090.97",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6914,LYMPHOMA MYELOMA and NONACUTE LEUKEMIA,,Relative Weights,"$18,806.65 ",IP,"18,806.65","18,806.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6921,RADIOTHERAPY,,Relative Weights,"$5,028.28 ",IP,"5,028.28","5,028.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6922,RADIOTHERAPY,,Relative Weights,"$8,603.36 ",IP,"8,603.36","8,603.36",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6923,RADIOTHERAPY,,Relative Weights,"$11,232.45 ",IP,"11,232.45","11,232.45",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6924,RADIOTHERAPY,,Relative Weights,"$22,232.95 ",IP,"22,232.95","22,232.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6941,LYMPHATIC & OTHER MALIGNANCIES & NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$3,669.93 ",IP,"3,669.93","3,669.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6942,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$4,230.04 ",IP,"4,230.04","4,230.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6943,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$5,867.41 ",IP,"5,867.41","5,867.41",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6944,LYMPHATIC and OTHER MALIGNANCIES and NEOPLASMS OF UNCERTAIN BEHAVIOR,,Relative Weights,"$11,092.25 ",IP,"11,092.25","11,092.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6951,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$3,844.14 ",IP,"3,844.14","3,844.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6952,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$4,908.70 ",IP,"4,908.70","4,908.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6953,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$11,375.74 ",IP,"11,375.74","11,375.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6954,CHEMOTHERAPY FOR ACUTE LEUKEMIA,,Relative Weights,"$32,868.17 ",IP,"32,868.17","32,868.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6961,OTHER CHEMOTHERAPY,,Relative Weights,"$4,174.03 ",IP,"4,174.03","4,174.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6962,OTHER CHEMOTHERAPY,,Relative Weights,"$5,397.68 ",IP,"5,397.68","5,397.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6963,OTHER CHEMOTHERAPY,,Relative Weights,"$7,757.01 ",IP,"7,757.01","7,757.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,6964,OTHER CHEMOTHERAPY,,Relative Weights,"$17,845.53 ",IP,"17,845.53","17,845.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7101,INFECTIOUS & PARASITIC DISEASES INCLUDING HIV W O.R. PROCEDURE,,Relative Weights,"$5,318.64 ",IP,"5,318.64","5,318.64",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7102,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$7,922.30 ",IP,"7,922.30","7,922.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7103,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$12,117.63 ",IP,"12,117.63","12,117.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7104,INFECTIOUS and PARASITIC DISEASES INCLUDING HIV W OR PROCEDURE,,Relative Weights,"$24,582.32 ",IP,"24,582.32","24,582.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7111,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$5,432.73 ",IP,"5,432.73","5,432.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7112,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$7,124.05 ",IP,"7,124.05","7,124.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7113,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$12,166.42 ",IP,"12,166.42","12,166.42",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7114,POSTOP POSTTRAUMA OTHER DEVICE INFECTIONS W OR PROCEDURE,,Relative Weights,"$25,010.82 ",IP,"25,010.82","25,010.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7201,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$2,801.24 ",IP,"2,801.24","2,801.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7202,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$3,678.52 ",IP,"3,678.52","3,678.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7203,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$5,399.74 ",IP,"5,399.74","5,399.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7204,SEPTICEMIA and DISSEMINATED INFECTIONS,,Relative Weights,"$10,740.72 ",IP,"10,740.72","10,740.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7211,"POST-OPERATIVE, POST-TRAUMATIC, OTHER DEVICE INFECTIONS",,Relative Weights,"$2,917.38 ",IP,"2,917.38","2,917.38",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7212,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$3,837.27 ",IP,"3,837.27","3,837.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7213,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$6,182.18 ",IP,"6,182.18","6,182.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7214,POSTOPERATIVE POSTTRAUMATIC OTHER DEVICE INFECTIONS,,Relative Weights,"$12,158.86 ",IP,"12,158.86","12,158.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7221,FEVER,,Relative Weights,"$1,952.14 ",IP,"1,952.14","1,952.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7222,FEVER,,Relative Weights,"$2,920.13 ",IP,"2,920.13","2,920.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7223,FEVER,,Relative Weights,"$3,952.39 ",IP,"3,952.39","3,952.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7224,FEVER,,Relative Weights,"$6,941.25 ",IP,"6,941.25","6,941.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7231,VIRAL ILLNESS,,Relative Weights,"$1,908.50 ",IP,"1,908.50","1,908.50",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7232,VIRAL ILLNESS,,Relative Weights,"$2,685.44 ",IP,"2,685.44","2,685.44",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7233,VIRAL ILLNESS,,Relative Weights,"$4,131.07 ",IP,"4,131.07","4,131.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7234,VIRAL ILLNESS,,Relative Weights,"$10,429.39 ",IP,"10,429.39","10,429.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7241,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,048.31 ",IP,"3,048.31","3,048.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7242,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$3,655.49 ",IP,"3,655.49","3,655.49",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7243,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$5,820.68 ",IP,"5,820.68","5,820.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7244,OTHER INFECTIOUS and PARASITIC DISEASES,,Relative Weights,"$13,099.02 ",IP,"13,099.02","13,099.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7401,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,032.70 ",IP,"6,032.70","6,032.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7402,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$6,703.46 ",IP,"6,703.46","6,703.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7403,MENTAL ILLNESS DIAGNOSIS W O.R. PROCEDURE,,Relative Weights,"$13,324.79 ",IP,"13,324.79","13,324.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7404,MENTAL ILLNESS DIAGNOSIS W OR PROCEDURE,,Relative Weights,"$26,668.81 ",IP,"26,668.81","26,668.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7501,SCHIZOPHRENIA,,Relative Weights,"$2,530.12 ",IP,"2,530.12","2,530.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7502,SCHIZOPHRENIA,,Relative Weights,"$2,708.80 ",IP,"2,708.80","2,708.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7503,SCHIZOPHRENIA,,Relative Weights,"$4,799.08 ",IP,"4,799.08","4,799.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7504,SCHIZOPHRENIA,,Relative Weights,"$13,473.58 ",IP,"13,473.58","13,473.58",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7511,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$1,760.40 ",IP,"1,760.40","1,760.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7512,MAJOR DEPRESSIVE DISORDERS & OTHER/UNSPECIFIED PSYCHOSES,,Relative Weights,"$2,237.01 ",IP,"2,237.01","2,237.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7513,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$3,773.70 ",IP,"3,773.70","3,773.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7514,MAJOR DEPRESSIVE DISORDERS and OTHERUNSPECIFIED PSYCHOSES,,Relative Weights,"$8,518.14 ",IP,"8,518.14","8,518.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7521,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$1,687.20 ",IP,"1,687.20","1,687.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7522,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$2,102.30 ",IP,"2,102.30","2,102.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7523,DISORDERS OF PERSONALITY & IMPULSE CONTROL,,Relative Weights,"$3,885.72 ",IP,"3,885.72","3,885.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7524,DISORDERS OF PERSONALITY and IMPULSE CONTROL,,Relative Weights,"$13,737.14 ",IP,"13,737.14","13,737.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7531,BIPOLAR DISORDERS,,Relative Weights,"$1,873.11 ",IP,"1,873.11","1,873.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7532,BIPOLAR DISORDERS,,Relative Weights,"$2,183.40 ",IP,"2,183.40","2,183.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7533,BIPOLAR DISORDERS,,Relative Weights,"$3,541.07 ",IP,"3,541.07","3,541.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7534,BIPOLAR DISORDERS,,Relative Weights,"$10,043.84 ",IP,"10,043.84","10,043.84",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7541,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$1,523.64 ",IP,"1,523.64","1,523.64",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7542,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$2,007.46 ",IP,"2,007.46","2,007.46",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7543,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$3,012.23 ",IP,"3,012.23","3,012.23",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7544,DEPRESSION EXCEPT MAJOR DEPRESSIVE DISORDER,,Relative Weights,"$7,979.68 ",IP,"7,979.68","7,979.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7551,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$1,532.57 ",IP,"1,532.57","1,532.57",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7552,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$2,506.06 ",IP,"2,506.06","2,506.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7553,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$3,538.32 ",IP,"3,538.32","3,538.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7554,ADJUSTMENT DISORDERS and NEUROSES EXCEPT DEPRESSIVE DIAGNOSES,,Relative Weights,"$6,118.26 ",IP,"6,118.26","6,118.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7561,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$2,496.79 ",IP,"2,496.79","2,496.79",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7562,ACUTE ANXIETY & DELIRIUM STATES,,Relative Weights,"$3,057.58 ",IP,"3,057.58","3,057.58",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7563,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$3,397.43 ",IP,"3,397.43","3,397.43",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7564,ACUTE ANXIETY and DELIRIUM STATES,,Relative Weights,"$7,384.52 ",IP,"7,384.52","7,384.52",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7571,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$2,504.35 ",IP,"2,504.35","2,504.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7572,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$3,161.02 ",IP,"3,161.02","3,161.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7573,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$5,750.24 ",IP,"5,750.24","5,750.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7574,ORGANIC MENTAL HEALTH DISTURBANCES,,Relative Weights,"$15,933.94 ",IP,"15,933.94","15,933.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7581,BEHAVIORAL DISORDERS,,Relative Weights,"$2,326.35 ",IP,"2,326.35","2,326.35",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7582,BEHAVIORAL DISORDERS,,Relative Weights,"$2,881.65 ",IP,"2,881.65","2,881.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7583,BEHAVIORAL DISORDERS,,Relative Weights,"$4,037.26 ",IP,"4,037.26","4,037.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7584,BEHAVIORAL DISORDERS,,Relative Weights,"$5,464.00 ",IP,"5,464.00","5,464.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7591,EATING DISORDERS,,Relative Weights,"$4,564.04 ",IP,"4,564.04","4,564.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7592,EATING DISORDERS,,Relative Weights,"$5,955.04 ",IP,"5,955.04","5,955.04",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7593,EATING DISORDERS,,Relative Weights,"$9,440.78 ",IP,"9,440.78","9,440.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7594,EATING DISORDERS,,Relative Weights,"$12,954.01 ",IP,"12,954.01","12,954.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7601,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$2,553.48 ",IP,"2,553.48","2,553.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7602,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$3,467.19 ",IP,"3,467.19","3,467.19",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7603,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$6,902.07 ",IP,"6,902.07","6,902.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7604,OTHER MENTAL HEALTH DISORDERS,,Relative Weights,"$12,546.82 ",IP,"12,546.82","12,546.82",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7701,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$1,041.53 ",IP,"1,041.53","1,041.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7702,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$1,522.95 ",IP,"1,522.95","1,522.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7703,"DRUG & ALCOHOL ABUSE OR DEPENDENCE, LEFT AGAINST MEDICAL ADVICE",,Relative Weights,"$2,633.89 ",IP,"2,633.89","2,633.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7704,DRUG and ALCOHOL ABUSE OR DEPENDENCE LEFT AGAINST MEDICAL ADVICE,,Relative Weights,"$6,153.65 ",IP,"6,153.65","6,153.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7721,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$2,743.85 ",IP,"2,743.85","2,743.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7722,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$3,502.58 ",IP,"3,502.58","3,502.58",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7723,ALCOHOL and DRUG DEPENDENCE W REHAB OR REHABDETOX THERAPY,,Relative Weights,"$4,241.72 ",IP,"4,241.72","4,241.72",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7724,ALCOHOL & DRUG DEPENDENCE W REHAB OR REHAB/DETOX THERAPY,,Relative Weights,"$9,550.40 ",IP,"9,550.40","9,550.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7731,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,275.88 ",IP,"1,275.88","1,275.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7732,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$1,881.01 ",IP,"1,881.01","1,881.01",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7733,OPIOID ABUSE and DEPENDENCE,,Relative Weights,"$3,476.12 ",IP,"3,476.12","3,476.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7734,OPIOID ABUSE & DEPENDENCE,,Relative Weights,"$9,565.86 ",IP,"9,565.86","9,565.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7741,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,761.43 ",IP,"1,761.43","1,761.43",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7742,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$1,956.95 ",IP,"1,956.95","1,956.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7743,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$3,314.62 ",IP,"3,314.62","3,314.62",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7744,COCAINE ABUSE and DEPENDENCE,,Relative Weights,"$9,105.40 ",IP,"9,105.40","9,105.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7751,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$1,741.50 ",IP,"1,741.50","1,741.50",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7752,ALCOHOL ABUSE & DEPENDENCE,,Relative Weights,"$2,441.81 ",IP,"2,441.81","2,441.81",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7753,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$3,986.06 ",IP,"3,986.06","3,986.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7754,ALCOHOL ABUSE and DEPENDENCE,,Relative Weights,"$10,751.37 ",IP,"10,751.37","10,751.37",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7761,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$2,414.66 ",IP,"2,414.66","2,414.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7762,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$2,653.48 ",IP,"2,653.48","2,653.48",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7763,OTHER DRUG ABUSE & DEPENDENCE,,Relative Weights,"$4,175.40 ",IP,"4,175.40","4,175.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7764,OTHER DRUG ABUSE and DEPENDENCE,,Relative Weights,"$7,699.28 ",IP,"7,699.28","7,699.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7921,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,773.51 ",IP,"7,773.51","7,773.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7922,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$8,931.53 ",IP,"8,931.53","8,931.53",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7923,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$13,005.21 ",IP,"13,005.21","13,005.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7924,EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$27,591.45 ",IP,"27,591.45","27,591.45",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7931,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$4,608.37 ",IP,"4,608.37","4,608.37",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7932,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$6,350.90 ",IP,"6,350.90","6,350.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7933,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$9,808.12 ",IP,"9,808.12","9,808.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7934,MODERATELY EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$20,177.03 ",IP,"20,177.03","20,177.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7941,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,990.87 ",IP,"3,990.87","3,990.87",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7942,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,327.92 ",IP,"5,327.92","5,327.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7943,NONEXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$7,911.30 ",IP,"7,911.30","7,911.30",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,7944,NON-EXTENSIVE OR PROCEDURES FOR OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$16,457.28 ",IP,"16,457.28","16,457.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8101,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$2,594.03 ",IP,"2,594.03","2,594.03",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8102,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$3,420.11 ",IP,"3,420.11","3,420.11",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8103,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$5,351.98 ",IP,"5,351.98","5,351.98",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8104,HEMORRHAGE OR HEMATOMA DUE TO COMPLICATION,,Relative Weights,"$10,772.68 ",IP,"10,772.68","10,772.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8111,ALLERGIC REACTIONS,,Relative Weights,"$1,582.40 ",IP,"1,582.40","1,582.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8112,ALLERGIC REACTIONS,,Relative Weights,"$2,325.66 ",IP,"2,325.66","2,325.66",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8113,ALLERGIC REACTIONS,,Relative Weights,"$4,003.24 ",IP,"4,003.24","4,003.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8114,ALLERGIC REACTIONS,,Relative Weights,"$9,358.65 ",IP,"9,358.65","9,358.65",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8121,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$1,778.95 ",IP,"1,778.95","1,778.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8122,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$2,471.70 ",IP,"2,471.70","2,471.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8123,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$3,713.91 ",IP,"3,713.91","3,713.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8124,POISONING OF MEDICINAL AGENTS,,Relative Weights,"$7,487.95 ",IP,"7,487.95","7,487.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8131,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$2,963.09 ",IP,"2,963.09","2,963.09",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8132,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$3,546.91 ",IP,"3,546.91","3,546.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8133,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$5,048.90 ",IP,"5,048.90","5,048.90",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8134,OTHER COMPLICATIONS OF TREATMENT,,Relative Weights,"$10,108.45 ",IP,"10,108.45","10,108.45",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8151,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$2,225.32 ",IP,"2,225.32","2,225.32",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8152,"OTHER INJURY, POISONING & TOXIC EFFECT DIAGNOSES",,Relative Weights,"$3,062.74 ",IP,"3,062.74","3,062.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8153,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$5,006.29 ",IP,"5,006.29","5,006.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8154,OTHER INJURY POISONING and TOXIC EFFECT DIAGNOSES,,Relative Weights,"$14,243.99 ",IP,"14,243.99","14,243.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8161,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$2,832.85 ",IP,"2,832.85","2,832.85",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8162,TOXIC EFFECTS OF NONMEDICINAL SUBSTANCES,,Relative Weights,"$3,147.27 ",IP,"3,147.27","3,147.27",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8163,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$3,543.13 ",IP,"3,543.13","3,543.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8164,TOXIC EFFECTS OF NON-MEDICINAL SUBSTANCES,,Relative Weights,"$7,485.21 ",IP,"7,485.21","7,485.21",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8171,OVERDOSE,,Relative Weights,"$1,970.70 ",IP,"1,970.70","1,970.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8172,OVERDOSE,,Relative Weights,"$2,320.16 ",IP,"2,320.16","2,320.16",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8173,OVERDOSE,,Relative Weights,"$3,714.94 ",IP,"3,714.94","3,714.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8174,OVERDOSE,,Relative Weights,"$7,902.37 ",IP,"7,902.37","7,902.37",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8411,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$22,662.13 ",IP,"22,662.13","22,662.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8412,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$23,053.18 ",IP,"23,053.18","23,053.18",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8413,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$35,475.26 ",IP,"35,475.26","35,475.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8414,EXTENSIVE 3RD DEGREE BURNS W SKIN GRAFT,,Relative Weights,"$76,935.80 ",IP,"76,935.80","76,935.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8421,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$7,378.34 ",IP,"7,378.34","7,378.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8422,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$11,298.08 ",IP,"11,298.08","11,298.08",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8423,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$20,251.94 ",IP,"20,251.94","20,251.94",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8424,BURNS WITH SKIN GRAFT EXCEPT EXTENSIVE 3RD DEGREE BURNS,,Relative Weights,"$47,998.02 ",IP,"47,998.02","47,998.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8431,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,499.14 ",IP,"3,499.14","3,499.14",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8432,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,888.47 ",IP,"3,888.47","3,888.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8433,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$4,320.07 ",IP,"4,320.07","4,320.07",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8434,EXTENSIVE 3RD DEGREE OR FULL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$12,575.34 ",IP,"12,575.34","12,575.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8441,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$2,201.96 ",IP,"2,201.96","2,201.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8442,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$3,652.06 ",IP,"3,652.06","3,652.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8443,PARTIAL THICKNESS BURNS WO SKIN GRAFT,,Relative Weights,"$7,050.86 ",IP,"7,050.86","7,050.86",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8444,PARTIAL THICKNESS BURNS W/O SKIN GRAFT,,Relative Weights,"$19,183.95 ",IP,"19,183.95","19,183.95",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8501,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$9,879.93 ",IP,"9,879.93","9,879.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8502,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$12,498.36 ",IP,"12,498.36","12,498.36",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8503,PROCEDURE W DIAG OF REHAB AFTERCARE OR OTH CONTACT W HEALTH SERVICE,,Relative Weights,"$15,265.59 ",IP,"15,265.59","15,265.59",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8504,"PROCEDURE W DIAG OF REHAB, AFTERCARE OR OTH CONTACT W HEALTH SERVICE",,Relative Weights,"$33,306.29 ",IP,"33,306.29","33,306.29",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8601,REHABILITATION,REHABILITATION,Relative Weights,"$2,725.99 ",IP,"2,725.99","2,725.99",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8602,REHABILITATION,REHABILITATION,Relative Weights,"$2,784.40 ",IP,"2,784.40","2,784.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8603,REHABILITATION,REHABILITATION,Relative Weights,"$4,569.88 ",IP,"4,569.88","4,569.88",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8604,REHABILITATION,REHABILITATION,Relative Weights,"$7,353.25 ",IP,"7,353.25","7,353.25",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8611,"SIGNS, SYMPTOMS & OTHER FACTORS INFLUENCING HEALTH STATUS",,Relative Weights,"$2,528.74 ",IP,"2,528.74","2,528.74",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8612,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$3,061.36 ",IP,"3,061.36","3,061.36",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8613,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$4,043.10 ",IP,"4,043.10","4,043.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8614,SIGNS SYMPTOMS and OTHER FACTORS INFLUENCING HEALTH STATUS,,Relative Weights,"$7,783.47 ",IP,"7,783.47","7,783.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8621,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$2,738.70 ",IP,"2,738.70","2,738.70",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8622,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$3,392.96 ",IP,"3,392.96","3,392.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8623,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$4,971.92 ",IP,"4,971.92","4,971.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8624,OTHER AFTERCARE and CONVALESCENCE,,Relative Weights,"$9,845.92 ",IP,"9,845.92","9,845.92",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8631,NEONATAL AFTERCARE,,Relative Weights,"$4,260.96 ",IP,"4,260.96","4,260.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8632,NEONATAL AFTERCARE,,Relative Weights,"$10,340.39 ",IP,"10,340.39","10,340.39",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8633,NEONATAL AFTERCARE,,Relative Weights,"$23,505.05 ",IP,"23,505.05","23,505.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8634,NEONATAL AFTERCARE,,Relative Weights,"$48,982.51 ",IP,"48,982.51","48,982.51",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8901,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$3,464.78 ",IP,"3,464.78","3,464.78",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8902,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$4,475.73 ",IP,"4,475.73","4,475.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8903,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$6,306.22 ",IP,"6,306.22","6,306.22",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8904,HIV W MULTIPLE MAJOR HIV RELATED CONDITIONS,,Relative Weights,"$13,523.40 ",IP,"13,523.40","13,523.40",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8921,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$3,450.69 ",IP,"3,450.69","3,450.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8922,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,178.15 ",IP,"4,178.15","4,178.15",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8923,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$4,816.26 ",IP,"4,816.26","4,816.26",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8924,HIV W MAJOR HIV RELATED CONDITION,,Relative Weights,"$8,453.20 ",IP,"8,453.20","8,453.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8931,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$2,817.73 ",IP,"2,817.73","2,817.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8932,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$4,010.80 ",IP,"4,010.80","4,010.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8933,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$5,201.12 ",IP,"5,201.12","5,201.12",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8934,HIV W MULTIPLE SIGNIFICANT HIV RELATED CONDITIONS,,Relative Weights,"$9,134.61 ",IP,"9,134.61","9,134.61",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8941,HIV W ONE SIGNIF HIV COND OR W/O SIGNIF RELATED COND,,Relative Weights,"$2,969.96 ",IP,"2,969.96","2,969.96",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8942,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$3,496.05 ",IP,"3,496.05","3,496.05",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8943,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$4,518.34 ",IP,"4,518.34","4,518.34",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,8944,HIV W ONE SIGNIF HIV COND OR WO SIGNIF RELATED COND,,Relative Weights,"$6,751.91 ",IP,"6,751.91","6,751.91",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9101,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$13,920.63 ",IP,"13,920.63","13,920.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9102,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$15,317.47 ",IP,"15,317.47","15,317.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9103,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$18,619.37 ",IP,"18,619.37","18,619.37",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9104,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$36,457.00 ",IP,"36,457.00","36,457.00",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9111,EXTENSIVE ABDOMINAL/THORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$7,838.80 ",IP,"7,838.80","7,838.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9112,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$10,303.63 ",IP,"10,303.63","10,303.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9113,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$13,414.47 ",IP,"13,414.47","13,414.47",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9114,EXTENSIVE ABDOMINALTHORACIC PROCEDURES FOR MULT SIGNIFICANT TRAUMA,,Relative Weights,"$32,085.73 ",IP,"32,085.73","32,085.73",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9121,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$8,688.93 ",IP,"8,688.93","8,688.93",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9122,MUSCULOSKELETAL and OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$9,567.24 ",IP,"9,567.24","9,567.24",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9123,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$14,948.76 ",IP,"14,948.76","14,948.76",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9124,MUSCULOSKELETAL & OTHER PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,,Relative Weights,"$30,211.60 ",IP,"30,211.60","30,211.60",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9301,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$3,875.76 ",IP,"3,875.76","3,875.76",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9302,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$4,609.06 ",IP,"4,609.06","4,609.06",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9303,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$7,139.17 ",IP,"7,139.17","7,139.17",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9304,MULTIPLE SIGNIFICANT TRAUMA WO OR PROCEDURE,,Relative Weights,"$15,709.89 ",IP,"15,709.89","15,709.89",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9501,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,265.63 ",IP,"7,265.63","7,265.63",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9502,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,410.20 ",IP,"9,410.20","9,410.20",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9503,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$12,679.80 ",IP,"12,679.80","12,679.80",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9504,EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$27,388.02 ",IP,"27,388.02","27,388.02",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9511,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$5,641.31 ",IP,"5,641.31","5,641.31",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9512,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$7,394.49 ",IP,"7,394.49","7,394.49",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9513,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$11,184.68 ",IP,"11,184.68","11,184.68",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9514,MODERATELY EXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$22,584.13 ",IP,"22,584.13","22,584.13",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9521,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$4,663.69 ",IP,"4,663.69","4,663.69",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9522,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$6,212.76 ",IP,"6,212.76","6,212.76",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9523,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$9,852.10 ",IP,"9,852.10","9,852.10",,,,,,,,,,,,
Molina Healthcare of IL MCD,DRG,9524,NONEXTENSIVE PROCEDURE UNRELATED TO PRINCIPAL DIAGNOSIS,,Relative Weights,"$20,519.28 ",IP,"20,519.28","20,519.28",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,100,Anesth salivary gland,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,102,Anesth repair of cleft lip,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,103,Anesth blepharoplasty,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,104,Anesth electroshock,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,120,Anesth ear surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,124,Anesth ear exam,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,126,Anesth tympanotomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,140,Anesth procedures on eye,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,142,Anesth lens surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,144,Anesth corneal transplant,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,145,Anesth vitreoretinal surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,147,Anesth iridectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,148,Anesth eye exam,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,160,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,162,Anesth nose/sinus surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,164,Anesth biopsy of nose,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,170,Anesth procedure on mouth,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,172,Anesth cleft palate repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,174,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,176,Anesth pharyngeal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,190,Anesth face/skull bone surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,192,Anesth facial bone surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,210,Anesth cranial surg nos,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,211,Anesth cran surg hemotoma,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,212,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,214,Anesth skull drainage,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,215,Anesth skull repair/fract,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,216,Anesth head vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,218,Anesth special head surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,220,Anesth intrcrn nerve,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,222,Anesth head nerve surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,300,Anesth head/neck/ptrunk,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,320,Anesth neck organ 1yr/>,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,322,Anesth biopsy of thyroid,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,326,Anesth larynx/trach < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,350,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,352,Anesth neck vessel surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,400,Anesth skin ext/per/atrunk,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,402,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,404,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,406,Anesth surgery of breast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,410,Anesth correct heart rhythm,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,450,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,454,Anesth collar bone biopsy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,470,Anesth removal of rib,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,472,Anesth chest wall repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,474,Anesth surgery of rib,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,500,Anesth esophageal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,520,Anesth chest procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,522,Anesth chest lining biopsy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,524,Anesth chest drainage,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,528,Anes mediascpy & dx thorscpy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,529,Anes medscpy&thorscpy 1 lung,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,530,Anesth pacemaker insertion,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,532,Anesth vascular access,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,534,Anesth cardioverter/defib,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,537,Anesth cardiac electrophys,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,539,Anesth trach-bronch reconst,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,540,Anesth chest surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,541,Anesth one lung ventilation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,542,Anesthesia removal pleura,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,546,Anesth lung chest wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,548,Anesth trachea bronchi surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,550,Anesth sternal debridement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,560,Anesth heart surg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,561,Anesth heart surg <1 yr,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,562,Anesth hrt surg w/pmp age 1+,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,563,Anesth heart surg w/arrest,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,566,Anesth cabg w/o pump,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,567,Anesth cabg w/pump,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,580,Anesth heart/lung transplnt,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,600,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,604,Anesth sitting procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,620,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,625,Anes spine tranthor w/o vent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,626,Anes spine transthor w/vent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,630,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,632,Anesth removal of nerves,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,635,Anesth lumbar puncture,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,640,Anesth spine manipulation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,670,Anesth spine cord surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,700,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,702,Anesth for liver biopsy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,730,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,731,Anes upr gi ndsc px nos,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,732,Anes upr gi ndsc px ercp,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,740,Anesth upper gi visualize,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,750,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,752,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,754,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,756,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,770,Anesth blood vessel repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,790,Anesth surg upper abdomen,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,792,Anesth hemorr/excise liver,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,794,Anesth pancreas removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,796,Anesth for liver transplant,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,797,Anesth surgery for obesity,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,800,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,802,Anesth fat layer removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,810,Anesth low intestine scope,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,811,Anes lwr intst ndsc nos,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,812,Anes lwr intst scr colsc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,813,Anes upr lwr gi ndsc px,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,820,Anesth abdominal wall surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,830,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,832,Anesth repair of hernia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,834,Anesth hernia repair < 1 yr,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,836,Anesth hernia repair preemie,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,840,Anesth surg lower abdomen,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,842,Anesth amniocentesis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,844,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,846,Anesth hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,848,Anesth pelvic organ surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,851,Anesth tubal ligation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,860,Anesth surgery of abdomen,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,862,Anesth kidney/ureter surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,864,Anesth removal of bladder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,865,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,866,Anesth removal of adrenal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,868,Anesth kidney transplant,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,870,Anesth bladder stone surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,872,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,873,Anesth kidney stone destruct,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,880,Anesth abdomen vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,882,Anesth major vein ligation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,902,Anesth anorectal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,904,Anesth perineal surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,906,Anesth removal of vulva,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,908,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,910,Anesth bladder surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,912,Anesth bladder tumor surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,914,Anesth removal of prostate,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,916,Anesth bleeding control,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,918,Anesth stone removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,920,Anesth genitalia surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,921,Anesth vasectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,922,Anesth sperm duct surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,924,Anesth testis exploration,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,926,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,928,Anesth removal of testis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,930,Anesth testis suspension,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,932,Anesth amputation of penis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,934,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,936,Anesth penis nodes removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,938,Anesth insert penis device,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,940,Anesth vaginal procedures,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,942,Anesth surg on vag/urethral,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,944,Anesth vaginal hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,948,Anesth repair of cervix,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,950,Anesth vaginal endoscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,952,Anesth hysteroscope/graph,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1112,Anesth bone aspirate/bx,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1120,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1130,Anesth body cast procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1140,Anesth amputation at pelvis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1150,Anesth pelvic tumor surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1160,Anesth pelvis procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1170,Anesth pelvis surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1173,Anesth fx repair pelvis,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1180,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1190,Anesth pelvis nerve removal,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1200,Anesth hip joint procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1202,Anesth arthroscopy of hip,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1210,Anesth hip joint surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1212,Anesth hip disarticulation,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1214,Anesth hip arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1215,Anesth revise hip repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1220,Anesth procedure on femur,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1230,Anesth surgery of femur,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1232,Anesth amputation of femur,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1234,Anesth radical femur surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1250,Anesth upper leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1260,Anesth upper leg veins surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1270,Anesth thigh arteries surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1272,Anesth femoral artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1274,Anesth femoral embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1320,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1340,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1360,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1380,Anesth knee joint procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1382,Anesth dx knee arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1390,Anesth knee area procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1392,Anesth knee area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1400,Anesth knee joint surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1402,Anesth knee arthroplasty,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1404,Anesth amputation at knee,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1420,Anesth knee joint casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1430,Anesth knee veins surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1432,Anesth knee vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1440,Anesth knee arteries surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1442,Anesth knee artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1444,Anesth knee artery repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1462,Anesth lower leg procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1464,Anesth ankle/ft arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1470,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1472,Anesth achilles tendon surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1474,Anesth lower leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1480,Anesth lower leg bone surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1482,Anesth radical leg surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1484,Anesth lower leg revision,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1486,Anesth ankle replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1490,Anesth lower leg casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1500,Anesth leg arteries surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1502,Anesth lwr leg embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1520,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1522,Anesth lower leg vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1610,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1620,Anesth shoulder procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1622,Anes dx shoulder arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1630,Anesth surgery of shoulder,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1634,Anesth shoulder joint amput,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1636,Anesth forequarter amput,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1638,Anesth shoulder replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1650,Anesth shoulder artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1652,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1654,Anesth shoulder vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1656,Anesth arm-leg vessel surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1670,Anesth shoulder vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1680,Anesth shoulder casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1682,Anesth airplane cast,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1710,Anesth elbow area surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1712,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1714,Anesth uppr arm tendon surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1716,Anesth biceps tendon repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1730,Anesth uppr arm procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1732,Anesth dx elbow arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1740,Anesth upper arm surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1742,Anesth humerus surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1744,Anesth humerus repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1756,Anesth radical humerus surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1758,Anesth humeral lesion surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1760,Anesth elbow replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1770,Anesth uppr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1772,Anesth uppr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1780,Anesth upper arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1782,Anesth uppr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1810,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1820,Anesth lower arm procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1829,Anesth dx wrist arthroscopy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1830,Anesth lower arm surgery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1832,Anesth wrist replacement,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1840,Anesth lwr arm artery surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1842,Anesth lwr arm embolectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1844,Anesth vascular shunt surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1850,Anesth lower arm vein surg,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1852,Anesth lwr arm vein repair,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1860,Anesth lower arm casting,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1916,Anesth dx arteriography,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1920,Anesth catheterize heart,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1922,Anesth cat or mri scan,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1924,Anes ther interven rad artrl,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1925,Anes ther interven rad card,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1926,Anes tx interv rad hrt/cran,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1930,Anes ther interven rad vein,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1931,Anes ther interven rad tips,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1932,Anes tx interv rad th vein,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1933,Anes tx interv rad cran vein,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1935,Anesth perc img dx sp proc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1936,Anesth perc img tx sp proc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1951,Anesth burn less 4 percent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1952,Anesth burn 4-9 percent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1953,Anesth burn each 9 percent,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1958,Anesth antepartum manipul,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1960,Anesth vaginal delivery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1961,Anesth cs delivery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1962,Anesth emer hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1963,Anesth cs hysterectomy,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1965,Anesth inc/missed ab proc,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1966,Anesth induced ab procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1967,Anesth/analg vag delivery,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1968,Anes/analg cs deliver add-on,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1969,Anesth/analg cs hyst add-on,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1991,Anesth nerve block/inj,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1992,Anesth n block/inj prone,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1996,Hosp manage cont drug admin,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,1999,Unlisted anesth procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10004,Fna bx w/o img gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10005,Fna bx w/us gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10006,Fna bx w/us gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10007,Fna bx w/fluor gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10008,Fna bx w/fluor gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10009,Fna bx w/ct gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10010,Fna bx w/ct gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10011,Fna bx w/mr gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10012,Fna bx w/mr gdn ea addl,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10021,Fna bx w/o img gdn 1st les,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10022,Fna w/image,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10030,Guide cathet fluid drainage,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10040,Acne surgery,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10060,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10061,Drainage of skin abscess,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10080,Drainage of pilonidal cyst,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10081,Drainage of pilonidal cyst,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10120,Remove foreign body,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10121,Remove foreign body,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10140,Drainage of hematoma/fluid,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,10160,Puncture drainage of lesion,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11055,Trim skin lesion,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11056,Trim skin lesions 2 to 4,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11057,Trim skin lesions over 4,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11100,Biopsy skin lesion,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11101,Biopsy skin add-on,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11102,Tangntl bx skin single les,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11103,Tangntl bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11104,Punch bx skin single lesion,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11105,Punch bx skin ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11106,Incal bx skn single les,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11107,Incal bx skn ea sep/addl,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11200,Removal of skin tags 2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11305,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11306,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11307,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11308,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11310,Shave skin lesion 0.5 cm/<,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11311,Shave skin lesion 0.6-1.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11312,Shave skin lesion 1.1-2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11313,Shave skin lesion >2.0 cm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11400,Exc tr-ext b9+marg 0.5 cm<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11401,Exc tr-ext b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11402,Exc tr-ext b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11403,Exc tr-ext b9+marg 2.1-3cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11404,Exc tr-ext b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11406,Exc tr-ext b9+marg >4.0 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11420,Exc h-f-nk-sp b9+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11421,Exc h-f-nk-sp b9+marg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11422,Exc h-f-nk-sp b9+marg 1.1-2,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11423,Exc h-f-nk-sp b9+marg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11424,Exc h-f-nk-sp b9+marg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11426,Exc h-f-nk-sp b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11440,Exc face-mm b9+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11441,Exc face-mm b9+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11442,Exc face-mm b9+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11443,Exc face-mm b9+marg 2.1-3 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11444,Exc face-mm b9+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11446,Exc face-mm b9+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11450,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11451,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11462,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11463,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11470,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11471,Removal sweat gland lesion,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11600,Exc tr-ext mal+marg 0.5 cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11601,Exc tr-ext mal+marg 0.6-1 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11602,Exc tr-ext mal+marg 1.1-2 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11603,Exc tr-ext mal+marg 2.1-3 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11604,Exc tr-ext mal+marg 3.1-4 cm,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11606,Exc tr-ext mal+marg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11620,Exc h-f-nk-sp mal+marg 0.5/<,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11621,Exc s/n/h/f/g mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11622,Exc s/n/h/f/g mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11623,Exc s/n/h/f/g mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11624,Exc s/n/h/f/g mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11626,Exc s/n/h/f/g mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11640,Exc f/e/e/n/l mal+mrg 0.5cm<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11641,Exc f/e/e/n/l mal+mrg 0.6-1,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11642,Exc f/e/e/n/l mal+mrg 1.1-2,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11643,Exc f/e/e/n/l mal+mrg 2.1-3,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11644,Exc f/e/e/n/l mal+mrg 3.1-4,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11646,Exc f/e/e/n/l mal+mrg >4 cm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11719,Trim nail(s) any number,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11720,Debride nail 1-5,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11721,Debride nail 6 or more,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11730,Removal of nail plate,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11732,Remove nail plate add-on,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11740,Drain blood from under nail,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11750,Removal of nail bed,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11752,Remove nail bed/tip,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11755,Biopsy nail unit,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11760,Repair of nail bed,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11762,Reconstruction of nail bed,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11765,Excision of nail fold toe,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11770,Remove pilonidal cyst simple,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11771,Remove pilonidal cyst exten,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11772,Remove pilonidal cyst compl,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11900,Inject skin lesions 7,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11920,Correct skin color 6.0 cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11921,Correct skn color 6.1-20.0cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11922,Correct skin color ea 20.0cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11950,Tx contour defects 1 cc/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11951,Tx contour defects 1.1-5.0cc,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11952,Tx contour defects 5.1-10cc,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11954,Tx contour defects >10.0 cc,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11960,Insert tissue expander(s),General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11971,Rmvl tis xpndr wo insj implt,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11976,Remove contraceptive capsule,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11980,Implant hormone pellet(s),General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11981,Insert drug implant device,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11982,Remove drug implant device,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,11983,Remove/insert drug implant,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13100,Cmplx rpr trunk 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13101,Cmplx rpr trunk 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13102,Cmplx rpr trunk addl 5cm/<,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13120,Cmplx rpr s/a/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13121,Cmplx rpr s/a/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13122,Cmplx rpr s/a/l addl 5 cm/>,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13131,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13132,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13133,Cmplx rpr f/c/c/m/n/ax/g/h/f,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13151,Cmplx rpr e/n/e/l 1.1-2.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13152,Cmplx rpr e/n/e/l 2.6-7.5 cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,13153,Cmplx rpr e/n/e/l addl 5cm/<,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15050,Skin pinch graft,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15775,Hair trnspl 1-15 punch grfts,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15776,Hair trnspl >15 punch grafts,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15780,Dermabrasion total face,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15781,Dermabrasion segmental face,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15782,Dermabrasion other than face,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15783,Dermabrasion suprfl any site,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15786,Abrasion lesion single,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15787,Abrasion lesions add-on,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15788,Chemical peel face epiderm,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15789,Chemical peel face dermal,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15792,Chemical peel nonfacial,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15793,Chemical peel nonfacial,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15819,Plastic surgery neck,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15820,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15821,Revision of lower eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15822,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15823,Revision of upper eyelid,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15824,Removal of forehead wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15825,Removal of neck wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15826,Removal of brow wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15828,Removal of face wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15829,Removal of skin wrinkles,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15830,Exc skin abd,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15832,Excise excessive skin thigh,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15833,Excise excessive skin leg,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15834,Excise excessive skin hip,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15835,Excise excessive skin buttck,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15836,Excise excessive skin arm,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15837,Excise excess skin arm/hand,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15838,Excise excess skin fat pad,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15839,Excise excess skin & tissue,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15847,Exc skin abd add-on,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15850,Remove sutures same surgeon,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15851,Remove sutures diff surgeon,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15876,Suction lipectomy head&neck,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15877,Suction lipectomy trunk,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15878,Suction lipectomy upr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,15879,Suction lipectomy lwr extrem,General Surgery,Per Unit,"$1,792.83 ",OP,"$1,792.83 ","$1,792.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17000,Destruct premalg lesion,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17003,Destruct premalg les 2-14,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17004,Destroy premal lesions 15/>,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17106,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17107,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17108,Destruction of skin lesions,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17110,Destruct b9 lesion 1-14,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17111,Destruct lesion 15 or more,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17250,Chem caut of granltj tissue,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17260,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17261,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17262,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17263,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17264,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17266,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17270,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17271,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17272,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17273,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17274,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17276,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17280,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17281,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17282,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17283,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17284,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17286,Destruction of skin lesions,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17340,Cryotherapy of skin,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17360,Skin peel therapy,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17380,Hair removal by electrolysis,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,17999,Skin tissue procedure,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19000,Drainage of breast lesion,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19001,Drain breast lesion add-on,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19020,Incision of breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19081,Bx breast 1st lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19082,Bx breast add lesion strtctc,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19083,Bx breast 1st lesion us imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19084,Bx breast add lesion us imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19085,Bx breast 1st lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19086,Bx breast add lesion mr imag,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19100,Bx breast percut w/o image,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19101,Biopsy of breast open,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19105,Cryosurg ablate fa each,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19110,Nipple exploration,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19112,Excise breast duct fistula,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19120,Removal of breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19125,Excision breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19126,Excision addl breast lesion,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19294,Prep tum cav iort prtl mast,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19297,Place breast cath for rad,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19298,Place breast rad tube/caths,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19300,Removal of breast tissue,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19301,Partial mastectomy,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19302,P-mastectomy w/ln removal,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19303,Mast simple complete,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19304,Mast subq,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19305,Mast radical,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19306,Mast rad urban type,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19307,Mast mod rad,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19316,Suspension of breast,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19318,Breast reduction,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19324,Enlarge breast,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19325,Breast augmentation w/implt,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19328,Rmvl intact breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19330,Rmvl ruptured breast implant,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19340,Insj breast implt sm d mast,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19342,Insj/rplcmt brst implt sep d,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19350,Breast reconstruction,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19355,Correct inverted nipple(s),General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19357,Tiss xpndr plmt brst rcnstj,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19361,Brst rcnstj latsms drsi flap,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19364,Brst rcnstj free flap,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19366,Breast reconstruction,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19367,Brst rcnstj 1 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19368,Brst rcnstj 1pdcl tram anast,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19369,Brst rcnstj 2 pdcl tram flap,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19370,Revj peri-implt capsule brst,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19371,Peri-implt capslc brst compl,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19380,Revj reconstructed breast,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19396,Design custom breast implant,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,19499,Breast surgery procedure,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20206,Needle biopsy muscle,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20220,Bone biopsy trocar/needle,General Surgery,Per Unit,$346.87 ,OP,$346.87 ,$346.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20500,Injection of sinus tract,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20526,Ther injection carp tunnel,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20527,Inj dupuytren cord w/enzyme,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20550,Inj tendon sheath/ligament,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20551,Inj tendon origin/insertion,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20552,Inj trigger point 1/2 muscl,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20553,Inject trigger points 3/>,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20560,Ndl insj w/o njx 1 or 2 musc,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20561,Ndl insj w/o njx 3+ musc,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20600,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20605,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20610,Drain/inj joint/bursa w/o us,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20612,Aspirate/inj ganglion cyst,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20822,Replantation digit complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20824,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20827,Replantation thumb complete,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20957,Mt bone graft microvasc,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20972,Bone/skin graft metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20973,Bone/skin graft great toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,20999,Musculoskeletal surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21010,Incision of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21025,Excision of bone lower jaw,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21030,Excise max/zygoma b9 tumor,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21031,Remove exostosis mandible,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21032,Remove exostosis maxilla,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21034,Excise max/zygoma mal tumor,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21040,Excise mandible lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21044,Removal of jaw bone lesion,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21045,Extensive jaw surgery,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21046,Remove mandible cyst complex,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21047,Excise lwr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21048,Remove maxilla cyst complex,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21049,Excis uppr jaw cyst w/repair,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21050,Removal of jaw joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21060,Remove jaw joint cartilage,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21070,Remove coronoid process,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21073,Mnpj of tmj w/anesth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21076,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21077,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21079,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21080,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21081,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21082,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21083,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21084,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21085,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21086,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21087,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21088,Prepare face/oral prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21089,Prepare face/oral prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21100,Maxillofacial fixation,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21110,Interdental fixation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21120,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21121,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21122,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21123,Reconstruction of chin,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21125,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21127,Augmentation lower jaw bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21138,Reduction of forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21172,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21175,Reconstruct orbit/forehead,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21193,Reconst lwr jaw w/o graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21195,Reconst lwr jaw w/o fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21196,Reconst lwr jaw w/fixation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21198,Reconstr lwr jaw segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21199,Reconstr lwr jaw w/advance,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21206,Reconstruct upper jaw bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21215,Lower jaw bone graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21235,Ear cartilage graft,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21240,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21242,Reconstruction of jaw joint,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21243,Reconstruction of jaw joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21244,Reconstruction of lower jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21245,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21246,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21248,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21249,Reconstruction of jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21270,Augmentation cheek bone,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21280,Revision of eyelid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21282,Revision of eyelid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21295,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21296,Revision of jaw muscle/bone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21315,Closed tx nose fx w/o stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21320,Closed tx nose fx w/ stablj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21336,Open tx septal fx w/wo stabj,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21337,Closed tx septal&nose fx,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21345,Closed tx nose/jaw fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21346,Opn tx nasomax fx w/fixj,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21400,Closed tx orbit w/o manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21401,Closed tx orbit w/manipulj,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21421,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21422,Treat mouth roof fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21440,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21445,Treat dental ridge fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21450,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21451,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21452,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21453,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21454,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21461,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21462,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21465,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21470,Treat lower jaw fracture,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21485,Reset dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21490,Repair dislocated jaw,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21495,Treat hyoid bone fracture,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21497,Interdental wiring,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21685,Hyoid myotomy & suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21805,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21811,Optx of rib fx w/fixj scope,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21812,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21813,Treatment of rib fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21820,Treat sternum fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,21825,Treat sternum fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,22305,Closed tx spine process fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,22310,Closed tx vert fx w/o manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,22315,Closed tx vert fx w/manj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,22505,Manipulation of spine,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,22515,Perq vertebral augmentation,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,22999,Abdomen surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23470,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23472,Reconstruct shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23473,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23474,Revis reconst shoulder joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23500,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23505,Treat clavicle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23515,Treat clavicle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23520,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23525,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23530,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23532,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23540,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23545,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23550,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23552,Treat clavicle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23570,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23575,Treat shoulder blade fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23585,Treat scapula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23600,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23605,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23615,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23616,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23620,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23625,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23630,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23650,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23655,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23660,Treat shoulder dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23665,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23670,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23675,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23680,Treat dislocation/fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23700,Fixation of shoulder,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,23929,Shoulder surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24300,Manipulate elbow w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24360,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24361,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24362,Reconstruct elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24363,Replace elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24365,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24366,Reconstruct head of radius,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24370,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24371,Revise reconst elbow joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24500,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24505,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24515,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24516,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24530,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24535,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24538,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24545,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24546,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24560,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24565,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24566,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24575,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24576,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24577,Treat humerus fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24579,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24582,Treat humerus fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24586,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24587,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24600,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24605,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24615,Treat elbow dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24620,Treat elbow fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24635,Treat elbow fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24640,Treat elbow dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24650,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24655,Treat radius fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24665,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24666,Treat radius fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24670,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24675,Treat ulnar fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24685,Treat ulnar fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,24999,Upper arm/elbow surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25001,Incise flexor carpi radialis,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25111,Remove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25112,Reremove wrist tendon lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25136,Remove & graft wrist lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25210,Removal of wrist bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25215,Removal of wrist bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25259,Manipulate wrist w/anesthes,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25315,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25316,Revise palsy hand tendon(s),Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25332,Revise wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25394,Repair carpal bone shorten,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25430,Vasc graft into carpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25431,Repair nonunion carpal bone,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25441,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25442,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25443,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25444,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25445,Reconstruct wrist joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25446,Wrist replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25447,Repair wrist joints,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25449,Remove wrist joint implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25500,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25505,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25515,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25520,Treat fracture of radius,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25525,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25526,Treat fracture of radius,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25530,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25535,Treat fracture of ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25545,Treat fracture of ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25560,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25565,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25574,Treat fracture radius & ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25575,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25600,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25605,Treat fracture radius/ulna,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25606,Treat fx distal radial,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25607,Treat fx rad extra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25608,Treat fx rad intra-articul,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25609,Treat fx radial 3+ frag,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25622,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25624,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25628,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25630,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25635,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25645,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25650,Treat wrist bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25651,Pin ulnar styloid fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25652,Treat fracture ulnar styloid,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25660,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25670,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25671,Pin radioulnar dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25675,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25676,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25680,Treat wrist fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25685,Treat wrist fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25690,Treat wrist dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25695,Treat wrist dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25820,Fusion of hand bones,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25825,Fuse hand bones with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25929,Amputation follow-up surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,25999,Forearm or wrist surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26010,Drainage of finger abscess,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26011,Drainage of finger abscess,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26020,Drain hand tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26025,Drainage of palm bursa,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26030,Drainage of palm bursas,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26034,Treat hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26035,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26037,Decompress fingers/hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26040,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26045,Release palm contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26055,Incise finger tendon sheath,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26060,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26070,Explore/treat hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26075,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26080,Explore/treat finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26100,Biopsy hand joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26105,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26110,Biopsy finger joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26111,Exc hand les sc 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26113,Exc hand tum deep 1.5 cm/>,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26115,Exc hand les sc < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26116,Exc hand tum deep < 1.5 cm,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26117,Rad resect hand tumor < 3 cm,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26118,Rad resect hand tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26121,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26123,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26125,Release palm contracture,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26130,Remove wrist joint lining,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26135,Revise finger joint each,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26140,Revise finger joint each,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26145,Tendon excision palm/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26160,Remove tendon sheath lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26170,Removal of palm tendon each,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26180,Removal of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26185,Remove finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26200,Remove hand bone lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26205,Remove/graft bone lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26210,Removal of finger lesion,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26215,Remove/graft finger lesion,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26230,Partial removal of hand bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26235,Partial removal finger bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26236,Partial removal finger bone,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26250,Extensive hand surgery,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26260,Resect prox finger tumor,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26262,Resect distal finger tumor,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26320,Removal of implant from hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26340,Manipulate finger w/anesth,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26341,Manipulat palm cord post inj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26350,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26352,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26356,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26357,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26358,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26370,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26372,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26373,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26390,Revise hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26392,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26410,Repair hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26412,Repair/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26415,Excision hand/finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26416,Graft hand or finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26418,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26420,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26426,Repair finger/hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26428,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26432,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26433,Repair finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26434,Repair/graft finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26437,Realignment of tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26440,Release palm/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26442,Release palm & finger tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26445,Release hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26449,Release forearm/hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26450,Incision of palm tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26455,Incision of finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26460,Incise hand/finger tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26471,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26474,Fusion of finger tendons,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26476,Tendon lengthening,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26477,Tendon shortening,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26478,Lengthening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26479,Shortening of hand tendon,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26480,Transplant hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26483,Transplant/graft hand tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26485,Transplant palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26489,Transplant/graft palm tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26490,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26492,Tendon transfer with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26494,Hand tendon/muscle transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26496,Revise thumb tendon,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26497,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26498,Finger tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26499,Revision of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26500,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26502,Hand tendon reconstruction,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26508,Release thumb contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26510,Thumb tendon transfer,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26516,Fusion of knuckle joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26517,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26518,Fusion of knuckle joints,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26520,Release knuckle contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26525,Release finger contracture,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26530,Revise knuckle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26531,Revise knuckle with implant,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26535,Revise finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26536,Revise/implant finger joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26540,Repair hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26541,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26542,Repair hand joint with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26545,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26546,Repair nonunion hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26548,Reconstruct finger joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26550,Construct thumb replacement,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26555,Positional change of finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26560,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26561,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26562,Repair of web finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26565,Correct metacarpal flaw,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26567,Correct finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26568,Lengthen metacarpal/finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26580,Repair hand deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26587,Reconstruct extra finger,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26590,Repair finger deformity,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26591,Repair muscles of hand,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26593,Release muscles of hand,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26596,Excision constricting tissue,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26600,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26605,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26607,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26608,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26615,Treat metacarpal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26641,Treat thumb dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26645,Treat thumb fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26650,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26665,Treat thumb fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26670,Treat hand dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26675,Treat hand dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26676,Pin hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26685,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26686,Treat hand dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26700,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26705,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26706,Pin knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26715,Treat knuckle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26720,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26725,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26727,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26735,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26740,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26742,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26746,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26750,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26755,Treat finger fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26756,Pin finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26765,Treat finger fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26770,Treat finger dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26775,Treat finger dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26776,Pin finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26785,Treat finger dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26820,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26841,Fusion of thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26842,Thumb fusion with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26843,Fusion of hand joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26844,Fusion/graft of hand joint,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26850,Fusion of knuckle,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26852,Fusion of knuckle with graft,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26860,Fusion of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26861,Fusion of finger jnt add-on,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26862,Fusion/graft of finger joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26863,Fuse/graft added joint,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26910,Amputate metacarpal bone,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26951,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,$661.08 ,OP,$661.08 ,$661.08 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26952,Amputation of finger/thumb,Orthopedic Surgery,Per Unit,"$1,085.51 ",OP,"$1,085.51 ","$1,085.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,26989,Hand/finger surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27125,Partial hip replacement,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27130,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27132,Total hip arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27134,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27137,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27138,Revise hip joint replacement,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27175,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27178,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27181,Treat slipped epiphysis,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27193,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27194,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27197,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27198,Clsd tx pelvic ring fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27200,Treat tail bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27202,Treat tail bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27215,Treat pelvic fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27216,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27217,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27218,Treat pelvic ring fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27220,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27222,Treat hip socket fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27226,Treat hip wall fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27227,Treat hip fracture(s),Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27230,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27232,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27235,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27236,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27238,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27240,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27246,Treat thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27248,Treat thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27250,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27252,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27253,Treat hip dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27256,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27257,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27265,Treat hip dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27266,Treat hip dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27267,Cltx thigh fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27268,Cltx thigh fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27269,Optx thigh fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27275,Manipulation of hip joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27299,Pelvis/hip joint surgery,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27412,Autochondrocyte implant knee,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27415,Osteochondral knee allograft,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27437,Revise kneecap,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27438,Revise kneecap with implant,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27440,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27441,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27442,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27443,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27445,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27446,Revision of knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27447,Total knee arthroplasty,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27486,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27487,Revise/replace knee joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27500,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27501,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27502,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27503,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27507,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27508,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27509,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27510,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27511,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27513,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27514,Treatment of thigh fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27516,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27517,Treat thigh fx growth plate,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27520,Treat kneecap fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27524,Treat kneecap fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27530,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27532,Treat knee fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27535,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27536,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27538,Treat knee fracture(s),Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27540,Treat knee fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27550,Treat knee dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27552,Treat knee dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27560,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27562,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27566,Treat kneecap dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27570,Fixation of knee joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27599,Leg surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27605,Incision of achilles tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27700,Revision of ankle joint,Orthopedic Surgery,Per Unit,"$1,410.56 ",OP,"$1,410.56 ","$1,410.56 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27702,Reconstruct ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27703,Reconstruction ankle joint,Orthopedic Surgery,Per Unit,"$4,978.29 ",OP,"$4,978.29 ","$4,978.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27720,Repair of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27722,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27724,Repair/graft of tibia,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27726,Repair fibula nonunion,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27750,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27752,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27756,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27758,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27759,Treatment of tibia fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27760,Cltx medial ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27762,Cltx med ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27766,Optx medial ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27767,Cltx post ankle fx,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27768,Cltx post ankle fx w/mnpj,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27769,Optx post ankle fx,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27780,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27781,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27784,Treatment of fibula fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27786,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27788,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27792,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27808,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27810,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27814,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27816,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27818,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27822,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27823,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27824,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27825,Treat lower leg fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27826,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27827,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27828,Treat lower leg fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27829,Treat lower leg joint,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27830,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27831,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27832,Treat lower leg dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27840,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27842,Treat ankle dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27846,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27848,Treat ankle dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27860,Fixation of ankle joint,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,27899,Leg/ankle surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28001,Drainage of bursa of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28002,Treatment of foot infection,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28005,Treat foot bone lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28008,Incision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28010,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28011,Incision of toe tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28020,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28022,Exploration of foot joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28024,Exploration of toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28039,Exc foot/toe tum sc 1.5 cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28041,Exc foot/toe tum dep 1.5cm/>,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28045,Exc foot/toe tum deep <1.5cm,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28046,Resect foot/toe tumor < 3 cm,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28047,Resect foot/toe tumor 3 cm/>,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28050,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28052,Biopsy of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28054,Biopsy of toe joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28055,Neurectomy foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28060,Partial removal foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28062,Removal of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28070,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28072,Removal of foot joint lining,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28080,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28086,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28088,Excise foot tendon sheath,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28090,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28092,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28100,Removal of ankle/heel lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28102,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28103,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28104,Removal of foot lesion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28106,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28107,Remove/graft foot lesion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28108,Removal of toe lesions,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28110,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28111,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28112,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28113,Part removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28114,Removal of metatarsal heads,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28116,Revision of foot,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28118,Removal of heel bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28119,Removal of heel spur,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28120,Part removal of ankle/heel,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28122,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28124,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28126,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28130,Removal of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28140,Removal of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28150,Removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28153,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28160,Partial removal of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28171,Resect tarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28173,Resect metatarsal tumor,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28175,Resect phalanx of toe tumor,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28190,Removal of foot foreign body,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28193,Removal of foot foreign body,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28200,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28202,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28208,Repair of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28210,Repair/graft of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28220,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28222,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28225,Release of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28226,Release of foot tendons,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28230,Incision of foot tendon(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28232,Incision of toe tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28234,Incision of foot tendon,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28238,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28240,Release of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28250,Revision of foot fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28260,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28261,Revision of foot tendon,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28262,Revision of foot and ankle,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28264,Release of midfoot joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28270,Release of foot contracture,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28272,Release of toe joint each,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28280,Fusion of toes,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28285,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28286,Repair of hammertoe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28288,Partial removal of foot bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28289,Corrj halux rigdus w/o implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28290,Correction of bunion,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28291,Corrj halux rigdus w/implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28292,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28293,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28294,Correction of bunion,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28295,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28296,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28297,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28298,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28299,Correction hallux valgus,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28300,Incision of heel bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28302,Incision of ankle bone,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28304,Incision of midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28305,Incise/graft midfoot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28306,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28307,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28308,Incision of metatarsal,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28309,Incision of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28310,Revision of big toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28312,Revision of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28313,Repair deformity of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28315,Removal of sesamoid bone,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28320,Repair of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28322,Repair of metatarsals,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28340,Resect enlarged toe tissue,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28341,Resect enlarged toe,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28344,Repair extra toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28345,Repair webbed toe(s),Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28360,Reconstruct cleft foot,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28400,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28405,Treatment of heel fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28406,Treatment of heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28415,Treat heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28420,Treat/graft heel fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28430,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28435,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28436,Treatment of ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28445,Treat ankle fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28446,Osteochondral talus autogrft,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28450,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28455,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28456,Treat midfoot fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28465,Treat midfoot fracture each,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28470,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28475,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28476,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28485,Treat metatarsal fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28490,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28495,Treat big toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28496,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28505,Treat big toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28510,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28515,Treatment of toe fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28525,Treat toe fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28530,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28531,Treat sesamoid bone fracture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28540,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28545,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28546,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28555,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28570,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28575,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28576,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28585,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28600,Treat foot dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28605,Treat foot dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28606,Treat foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28615,Repair foot dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28630,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28635,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28636,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28645,Repair toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28660,Treat toe dislocation,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28665,Treat toe dislocation,Orthopedic Surgery,Per Unit,$578.65 ,OP,$578.65 ,$578.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28666,Treat toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28675,Repair of toe dislocation,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28705,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28715,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28725,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28730,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28735,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28737,Revision of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28740,Fusion of foot bones,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28750,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28755,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28760,Fusion of big toe joint,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28805,Amputation thru metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28810,Amputation toe & metatarsal,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28820,Amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28825,Partial amputation of toe,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28890,Hi enrgy eswt plantar fascia,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,28899,Foot/toes surgery procedure,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29000,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29010,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29015,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29035,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29040,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29044,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29046,Application of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29049,Application of figure eight,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29055,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29058,Application of shoulder cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29065,Application of long arm cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29075,Application of forearm cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29085,Apply hand/wrist cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29086,Apply finger cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29105,Apply long arm splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29125,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29126,Apply forearm splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29130,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29131,Application of finger splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29200,Strapping of chest,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29240,Strapping of shoulder,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29260,Strapping of elbow or wrist,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29280,Strapping of hand or finger,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29305,Application of hip cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29325,Application of hip casts,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29345,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29355,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29358,Apply long leg cast brace,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29365,Application of long leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29405,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29425,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29435,Apply short leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29440,Addition of walker to cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29445,Apply rigid leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29450,Application of leg cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29505,Application long leg splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29515,Application lower leg splint,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29520,Strapping of hip,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29530,Strapping of knee,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29540,Strapping of ankle and/or ft,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29550,Strapping of toes,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29580,Application of paste boot,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29581,Apply multlay comprs lwr leg,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29582,Apply multlay comprs upr leg,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29583,Apply multlay comprs upr arm,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29584,Appl multlay comprs arm/hand,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29700,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29705,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29710,Removal/revision of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29720,Repair of body cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29730,Windowing of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29740,Wedging of cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29750,Wedging of clubfoot cast,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29799,Casting/strapping procedure,Orthopedics,Per Unit,$143.71 ,OP,$143.71 ,$143.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29800,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29804,Jaw arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29805,Sho arthrs dx +- synovial bx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29806,Sho arthrs srg capsulorpaphy,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29807,Sho arthrs srg rpr slap les,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29819,Sho arthrs srg rmvl loose/fb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29820,Sho arthrs srg prtl synvct,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29821,Sho arthrs srg compl synvct,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29822,Sho arthrs srg lmtd dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29823,Sho arthrs srg xtnsv dbrdmt,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29824,Sho arthrs srg dstl claviclc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29825,Sho arthrs srg lss&rescj ads,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29826,Sho arthrs srg decompression,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29827,Sho arthrs srg rt8tr cuf rpr,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29828,Sho arthrs srg bicp tenodsis,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29830,Elbow arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29834,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29835,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29836,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29837,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29838,Elbow arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29840,Wrist arthroscopy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29843,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29844,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29845,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29846,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29847,Wrist arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29848,Wrist endoscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29850,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29851,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29855,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29856,Tibial arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29860,Hip arthroscopy dx,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29861,Hip arthro w/fb removal,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29862,Hip arthr0 w/debridement,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29863,Hip arthr0 w/synovectomy,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29866,Autgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29867,Allgrft implnt knee w/scope,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29868,Meniscal trnspl knee w/scpe,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29870,Knee arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29871,Knee arthroscopy/drainage,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29873,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29874,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29875,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29876,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29877,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29879,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29880,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29881,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29882,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29883,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29884,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29885,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29886,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29887,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29888,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29889,Knee arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29891,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29892,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29893,Scope plantar fasciotomy,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29894,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29895,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29897,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29898,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29899,Ankle arthroscopy/surgery,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29900,Mcp joint arthroscopy dx,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29901,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29902,Mcp joint arthroscopy surg,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29904,Subtalar arthro w/fb rmvl,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29905,Subtalar arthro w/exc,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29906,Subtalar arthro w/deb,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29907,Subtalar arthro w/fusion,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29914,Hip arthro w/femoroplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29915,Hip arthro acetabuloplasty,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29916,Hip arthro w/labral repair,Orthopedic Surgery,Per Unit,"$2,793.83 ",OP,"$2,793.83 ","$2,793.83 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,29999,Arthroscopy of joint,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30020,Drainage of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30100,Intranasal biopsy,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30110,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30115,Removal of nose polyp(s),Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30117,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30118,Removal of intranasal lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30120,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30124,Removal of nose lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30125,Removal of nose lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30130,Excise inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30140,Resect inferior turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30150,Partial removal of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30160,Removal of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30200,Injection treatment of nose,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30220,Insert nasal septal button,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30310,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30320,Remove nasal foreign body,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30400,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30410,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30420,Reconstruction of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30430,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30435,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30450,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30460,Revision of nose,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30462,Revision of nose,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30465,Repair nasal stenosis,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30468,Rpr nsl vlv collapse w/implt,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30520,Repair of nasal septum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30540,Repair nasal defect,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30560,Release of nasal adhesions,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30580,Repair upper jaw fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30600,Repair mouth/nose fistula,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30620,Intranasal reconstruction,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30630,Repair nasal septum defect,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30801,Ablate inf turbinate superf,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30802,Ablate inf turbinate submuc,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30915,Ligation nasal sinus artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30920,Ligation upper jaw artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30930,Ther fx nasal inf turbinate,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,30999,Nasal surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31000,Irrigation maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31002,Irrigation sphenoid sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31020,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31030,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31032,Explore sinus remove polyps,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31050,Exploration sphenoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31051,Sphenoid sinus surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31070,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31075,Exploration of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31080,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31081,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31084,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31085,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31086,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31087,Removal of frontal sinus,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31090,Exploration of sinuses,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31200,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31201,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31205,Removal of ethmoid sinus,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31225,Removal of upper jaw,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31233,Nsl/sins ndsc dx max sinusc,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31235,Nsl/sins ndsc dx sphn sinusc,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31237,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31238,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31239,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31240,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31241,Nsl/sins ndsc w/artery lig,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31253,Nsl/sins ndsc total,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31254,Nsl/sins ndsc w/prtl ethmdct,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31255,Nsl/sins ndsc w/tot ethmdct,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31256,Exploration maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31257,Nsl/sins ndsc tot w/sphendt,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31259,Nsl/sins ndsc sphn tiss rmvl,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31267,Endoscopy maxillary sinus,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31276,Nsl/sins ndsc frnt tiss rmvl,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31287,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31288,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31290,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31291,Nasal/sinus endoscopy surg,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31292,Nsl/sins ndsc med/inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31293,Nsl/sins ndsc med&inf dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31294,Nsl/sins ndsc surg on dcmprn,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31295,Nsl/sins ndsc surg max sins,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31296,Nsl/sins ndsc surg frnt sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31297,Nsl/sins ndsc surg sphn sins,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31298,Nsl/sins ndsc surg frnt&sphn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31299,Sinus surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31300,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31320,Diagnostic incision larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31375,Partial removal of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31400,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31420,Removal of epiglottis,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31500,Insert emergency airway,General Medicine,Per Unit,$385.17 ,OP,$385.17 ,$385.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31510,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31512,Removal of larynx lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31513,Injection into vocal cord,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31515,Laryngoscopy for aspiration,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31520,Dx laryngoscopy newborn,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31525,Dx laryngoscopy excl nb,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31526,Dx laryngoscopy w/oper scope,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31527,Laryngoscopy for treatment,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31528,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31529,Laryngoscopy and dilation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31530,Laryngoscopy w/fb removal,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31531,Laryngoscopy w/fb & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31535,Laryngoscopy w/biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31536,Laryngoscopy w/bx & op scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31540,Laryngoscopy w/exc of tumor,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31541,Larynscop w/tumr exc + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31545,Remove vc lesion w/scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31546,Remove vc lesion scope/graft,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31551,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31552,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31553,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31554,Laryngoplasty laryngeal sten,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31560,Laryngoscop w/arytenoidectom,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31561,Larynscop remve cart + scop,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31570,Laryngoscope w/vc inj,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31571,Laryngoscop w/vc inj + scope,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31572,Largsc w/laser dstrj les,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31573,Largsc w/ther injection,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31574,Largsc w/njx augmentation,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31576,Laryngoscopy with biopsy,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31577,Largsc w/rmvl foreign bdy(s),Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31578,Largsc w/removal lesion,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31579,Laryngoscopy telescopic,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31580,Laryngoplasty laryngeal web,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31582,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31584,Laryngoplasty fx rdctj fixj,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31587,Laryngoplasty cricoid split,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31588,Revision of larynx,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31590,Reinnervate larynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31591,Laryngoplasty medialization,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31595,Larynx nerve surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31599,Larynx surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31615,Visualization of windpipe,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31622,Dx bronchoscope/wash,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31623,Dx bronchoscope/brush,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31624,Dx bronchoscope/lavage,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31625,Bronchoscopy w/biopsy(s),Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31626,Bronchoscopy w/markers,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31627,Navigational bronchoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31628,Bronchoscopy/lung bx each,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31629,Bronchoscopy/needle bx each,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31632,Bronchoscopy/lung bx addl,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31633,Bronchoscopy/needle bx addl,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31635,Bronchoscopy w/fb removal,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31643,Diag bronchoscope/catheter,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31645,Brnchsc w/ther aspir 1st,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31646,Brnchsc w/ther aspir sbsq,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31720,Clearance of airways,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31725,Clearance of airways,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,31899,Airways surgical procedure,Pulmonary,Per Unit,$987.23 ,OP,$987.23 ,$987.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33206,Insert heart pm atrial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33207,Insert heart pm ventricular,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33208,Insrt heart pm atrial & vent,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33212,Insert pulse gen sngl lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33213,Insert pulse gen dual leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33214,Upgrade of pacemaker system,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33221,Insert pulse gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33224,Insert pacing lead & connect,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33225,L ventric pacing lead add-on,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33226,Reposition l ventric lead,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33227,Remove&replace pm gen singl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33228,Remv&replc pm gen dual lead,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33229,Remv&replc pm gen mult leads,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33230,Insrt pulse gen w/dual leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33231,Insrt pulse gen w/mult leads,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33233,Removal of pm generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33240,Insrt pulse gen w/singl lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33241,Remove pulse generator,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33249,Insj/rplcmt defib w/lead(s),Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33262,Rmvl& replc pulse gen 1 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33263,Rmvl & rplcmt dfb gen 2 lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33264,Rmvl & rplcmt dfb gen mlt ld,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33270,Ins/rep subq defibrillator,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33274,Tcat insj/rpl perm ldls pm,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33275,Tcat rmvl perm ldls pm w/img,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33282,Implant pat-active ht record,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33285,Insj subq car rhythm mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33289,Tcat impl wrls p-art prs snr,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33889,Artery transpose/endovas taa,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33967,Insert i-aort percut device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33968,Remove aortic assist device,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33990,Insj perq vad l hrt arterial,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33991,Insj perq vad l hrt artl&ven,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33992,Rmvl perq left heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33993,Reposg perq r/l hrt vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33995,Insj perq vad r hrt venous,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33997,Rmvl perq right heart vad,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,33999,Cardiac surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34001,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34101,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34111,Removal of arm artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34201,Removal of artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34203,Removal of leg artery clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34421,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34471,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34490,Removal of vein clot,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34501,Repair valve femoral vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34510,Transposition of vein valve,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34520,Cross-over vein graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34530,Leg vein fusion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34714,Opn fem art expos cndt crtj,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34715,Opn ax/subcla art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34716,Opn ax/subcla art expos cndt,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34812,Opn fem art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,34834,Opn brach art expos,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35011,Repair defect of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35013,Repair artery rupture arm,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35045,Repair defect of arm artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35180,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35184,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35188,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35190,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35201,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35206,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35207,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35226,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35231,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35236,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35256,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35261,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35266,Repair blood vessel lesion,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35301,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35302,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35303,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35304,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35305,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35306,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35321,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35355,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35371,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35372,Rechanneling of artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35390,Reoperation carotid add-on,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35400,Angioscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35452,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35472,Repair arterial blockage,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35694,Art trnsposj subclav carotid,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35697,Reimplant artery each,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35700,Reoperation bypass graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35701,Expl n/flwd surg neck art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35702,Expl n/flwd surg uxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35703,Expl n/flwd surg lxtr art,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35721,Exploration femoral artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35741,Exploration popliteal artery,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35761,Exploration of artery/vein,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35800,Explore neck vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35820,Explore chest vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35860,Explore limb vessels,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35875,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35876,Removal of clot in graft,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35901,Excision graft neck,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,35903,Excision graft extremity,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36005,Injection ext venography,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36010,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36011,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36012,Place catheter in vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36013,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36014,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36015,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36100,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36120,Establish access to artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36140,Intro ndl icath upr/lxtr art,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36160,Establish access to aorta,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36200,Place catheter in aorta,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36215,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36216,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36217,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36218,Place catheter in artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36221,Place cath thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36222,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36223,Place cath carotid/inom art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36224,Place cath carotd art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36225,Place cath subclavian art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36226,Place cath vertebral art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36227,Place cath xtrnl carotid,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36228,Place cath intracranial art,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36245,Ins cath abd/l-ext art 1st,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36246,Ins cath abd/l-ext art 2nd,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36247,Ins cath abd/l-ext art 3rd,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36248,Ins cath abd/l-ext art addl,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36251,Ins cath ren art 1st unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36252,Ins cath ren art 1st bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36253,Ins cath ren art 2nd+ unilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36254,Ins cath ren art 2nd+ bilat,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36260,Insertion of infusion pump,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36299,Vessel injection procedure,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36430,Blood transfusion service,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36440,Bl push transfuse 2 yr/<,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36450,Bl exchange/transfuse nb,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36455,Bl exchange/transfuse non-nb,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36456,Prtl exchange transfuse nb,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36460,Transfusion service fetal,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36465,Njx noncmpnd sclrsnt 1 vein,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36466,Njx noncmpnd sclrsnt mlt vn,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36468,Njx sclrsnt spider veins,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36470,Njx sclrsnt 1 incmptnt vein,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36471,Njx sclrsnt mlt incmptnt vn,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36481,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36500,Insertion of catheter vein,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36511,Apheresis wbc,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36512,Apheresis rbc,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36513,Apheresis platelets,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36514,Apheresis plasma,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36515,Apheresis adsorp/reinfuse,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36516,Apheresis immunoads slctv,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36522,Photopheresis,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36557,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36558,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36560,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36561,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36563,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36565,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36566,Insert tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36581,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36582,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36583,Replace tunneled cv cath,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36593,Declot vascular device,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36620,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36625,Insertion catheter artery,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36640,Insertion catheter artery,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36680,Insert needle bone cavity,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36800,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36810,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36815,Insertion of cannula,Interventional Radiology,Per Unit,$970.64 ,OP,$970.64 ,$970.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36823,Insertion of cannula(s),Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36838,Dist revas ligation hemo,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36860,External cannula declotting,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36903,Intro cath dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36905,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36906,Thrmbc/nfs dialysis circuit,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36907,Balo angiop ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36908,Stent plmt ctr dialysis seg,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,36909,Dialysis circuit embolj,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37145,Revision of circulation,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37182,Insert hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37183,Remove hepatic shunt (tips),Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37184,Prim art m-thrmbc 1st vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37185,Prim art m-thrmbc sbsq vsl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37186,Sec art thrombectomy add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37195,Thrombolytic therapy stroke,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37202,Transcatheter therapy infuse,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37215,Transcath stent cca w/eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37216,Transcath stent cca w/o eps,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37217,Stent placemt retro carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37218,Stent placemt ante carotid,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37220,Iliac revasc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37221,Iliac revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37222,Iliac revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37223,Iliac revasc w/stent add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37224,Fem/popl revas w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37225,Fem/popl revas w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37226,Fem/popl revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37227,Fem/popl revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37228,Tib/per revasc w/tla,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37229,Tib/per revasc w/ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37230,Tib/per revasc w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37231,Tib/per revasc stent & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37232,Tib/per revasc add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37233,Tibper revasc w/ather add-on,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37234,Revsc opn/prq tib/pero stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37235,Tib/per revasc stnt & ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37236,Open/perq place stent 1st,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37237,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37238,Open/perq place stent same,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37239,Open/perq place stent ea add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37241,Vasc embolize/occlude venous,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37242,Vasc embolize/occlude artery,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37243,Vasc embolize/occlude organ,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37244,Vasc embolize/occlude bleed,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37247,Trluml balo angiop addl art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37249,Trluml balo angiop addl vein,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37250,Iv us first vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37251,Iv us each add vessel add-on,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37500,Endoscopy ligate perf veins,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37501,Vascular endoscopy procedure,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37565,Ligation of neck vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37600,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37605,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37606,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37607,Ligation of a-v fistula,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37609,Temporal artery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37615,Ligation of neck artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37618,Ligation of extremity artery,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37619,Ligation of inf vena cava,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37650,Revision of major vein,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37790,Penile venous occlusion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,37799,Vascular surgery procedure,Vascular Surgery,Per Unit,"$1,174.75 ",OP,"$1,174.75 ","$1,174.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38102,Removal of spleen total,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38120,Laparoscopy splenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38129,Laparoscope proc spleen,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38205,Harvest allogeneic stem cell,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38206,Harvest auto stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38207,Cryopreserve stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38208,Thaw preserved stem cells,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38209,Wash harvest stem cells,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38210,T-cell depletion of harvest,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38211,Tumor cell deplete of harvst,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38212,Rbc depletion of harvest,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38213,Platelet deplete of harvest,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38214,Volume deplete of harvest,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38215,Harvest stem cell concentrte,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38230,Bone marrow harvest allogen,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38232,Bone marrow harvest autolog,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38240,Transplt allo hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38241,Transplt autol hct/donor,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38242,Transplt allo lymphocytes,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38243,Transplj hematopoietic boost,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38300,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38305,Drainage lymph node lesion,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38308,Incision of lymph channels,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38380,Thoracic duct procedure,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38500,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38505,Needle biopsy lymph nodes,General Surgery,Per Unit,$734.97 ,OP,$734.97 ,$734.97 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38510,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38520,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38525,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38530,Biopsy/removal lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38531,Open bx/exc inguinofem nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38542,Explore deep node(s) neck,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38550,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38555,Removal neck/armpit lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38562,Removal pelvic lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38570,Laparoscopy lymph node biop,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38571,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38572,Laparoscopy lymphadenectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38573,Laps pelvic lymphadec,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38589,Laparoscope proc lymphatic,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38700,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38720,Removal of lymph nodes neck,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38724,Removal of lymph nodes neck,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38740,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38745,Remove armpit lymph nodes,General Surgery,Per Unit,"$1,609.30 ",OP,"$1,609.30 ","$1,609.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38747,Remove abdominal lymph nodes,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38760,Remove groin lymph nodes,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38792,Ra tracer id of sentinl node,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38794,Access thoracic lymph duct,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,38999,Blood/lymph system procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,39545,Revision of diaphragm,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,39599,Diaphragm surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40490,Biopsy of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40500,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40510,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40520,Partial excision of lip,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40525,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40527,Reconstruct lip with flap,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40530,Partial removal of lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40650,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40652,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40654,Repair lip,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40799,Lip surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40801,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40805,Removal foreign body mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40806,Incision of lip fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40808,Biopsy of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40810,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40812,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40814,Excise/repair mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40816,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40818,Excise oral mucosa for graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40819,Excise lip or cheek fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40820,Treatment of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40830,Repair mouth laceration,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40831,Repair mouth laceration,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40840,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40842,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40843,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40844,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40845,Reconstruction of mouth,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,40899,Mouth surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41000,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41005,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41006,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41007,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41008,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41009,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41010,Incision of tongue fold,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41015,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41016,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41017,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41018,Drainage of mouth lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41100,Biopsy of tongue,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41105,Biopsy of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41108,Biopsy of floor of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41110,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41112,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41113,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41114,Excision of tongue lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41115,Excision of tongue fold,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41116,Excision of mouth lesion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41120,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41130,Partial removal of tongue,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41135,Tongue and neck surgery,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41150,Tongue mouth jaw surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41500,Fixation of tongue,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41510,Tongue to lip surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41512,Tongue suspension,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41520,Reconstruction tongue fold,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41530,Tongue base vol reduction,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41599,Tongue and mouth surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41805,Removal foreign body gum,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41806,Removal foreign body jawbone,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41820,Excision gum each quadrant,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41821,Excision of gum flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41822,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41823,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41825,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41826,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41827,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41828,Excision of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41830,Removal of gum tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41850,Treatment of gum lesion,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41870,Gum graft,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41872,Repair gum,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41874,Repair tooth socket,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,41899,Dental surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42100,Biopsy roof of mouth,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42104,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42106,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42107,Excision lesion mouth roof,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42120,Remove palate/lesion,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42140,Excision of uvula,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42160,Treatment mouth roof lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42180,Repair palate,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42182,Repair palate,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42260,Repair nose to lip fistula,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42280,Preparation palate mold,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42281,Insertion palate prosthesis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42299,Palate/uvula surgery,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42300,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42305,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42310,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42320,Drainage of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42330,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42335,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42340,Removal of salivary stone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42400,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42405,Biopsy of salivary gland,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42408,Excision of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42409,Drainage of salivary cyst,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42410,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42415,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42420,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42425,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42426,Excise parotid gland/lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42440,Excise submaxillary gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42450,Excise sublingual gland,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42500,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42505,Repair salivary duct,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42507,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42509,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42510,Parotid duct diversion,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42600,Closure of salivary fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42650,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42660,Dilation of salivary duct,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42665,Ligation of salivary duct,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42699,Salivary surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42720,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42725,Drainage of throat abscess,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42800,Biopsy of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42804,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42806,Biopsy of upper nose/throat,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42808,Excise pharynx lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42810,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42815,Excision of neck cyst,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42820,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42821,Remove tonsils and adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42825,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42826,Removal of tonsils,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42830,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42831,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42835,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42836,Removal of adenoids,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42842,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42844,Extensive surgery of throat,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42860,Excision of tonsil tags,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42870,Excision of lingual tonsil,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42890,Partial removal of pharynx,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42892,Revision of pharyngeal walls,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42900,Repair throat wound,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42950,Reconstruction of throat,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42953,Repair throat esophagus,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42955,Surgical opening of throat,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42960,Control throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42962,Control throat bleeding,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42970,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42972,Control nose/throat bleeding,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,42999,Throat surgery procedure,Otolaryngology Surgery,Per Unit,"$1,027.68 ",OP,"$1,027.68 ","$1,027.68 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43020,Incision of esophagus,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43030,Throat muscle surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43100,Excision of esophagus lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43130,Removal of esophagus pouch,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43191,Esophagoscopy rigid trnso dx,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43192,Esophagoscp rig trnso inject,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43193,Esophagoscp rig trnso biopsy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43194,Esophagoscp rig trnso rem fb,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43196,Esophagoscp guide wire dilat,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43197,Esophagoscopy flex dx brush,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43198,Esophagosc flex trnsn biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43200,Esophagoscopy flexible brush,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43201,Esoph scope w/submucous inj,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43202,Esophagoscopy flex biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43204,Esoph scope w/sclerosis inj,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43205,Esophagus endoscopy/ligation,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43206,Esoph optical endomicroscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43211,Esophagoscop mucosal resect,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43213,Esophagoscopy retro balloon,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43214,Esophagosc dilate balloon 30,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43215,Esophagoscopy flex remove fb,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43216,Esophagoscopy lesion removal,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43217,Esophagoscopy snare les remv,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43220,Esophagoscopy balloon <30mm,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43226,Esoph endoscopy dilation,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43227,Esophagoscopy control bleed,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43229,Esophagoscopy lesion ablate,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43231,Esophagoscop ultrasound exam,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43232,Esophagoscopy w/us needle bx,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43233,Egd balloon dil esoph30 mm/>,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43235,Egd diagnostic brush wash,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43236,Uppr gi scope w/submuc inj,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43237,Endoscopic us exam esoph,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43238,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43239,Egd biopsy single/multiple,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43241,Egd tube/cath insertion,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43242,Egd us fine needle bx/aspir,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43243,Egd injection varices,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43244,Egd varices ligation,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43245,Egd dilate stricture,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43246,Egd place gastrostomy tube,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43247,Egd remove foreign body,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43248,Egd guide wire insertion,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43249,Esoph egd dilation <30 mm,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43250,Egd cautery tumor polyp,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43251,Egd remove lesion snare,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43253,Egd us transmural injxn/mark,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43254,Egd endo mucosal resection,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43255,Egd control bleeding any,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43257,Egd w/thrml txmnt gerd,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43259,Egd us exam duodenum/jejunum,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43260,Ercp w/specimen collection,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43261,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43262,Endo cholangiopancreatograph,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43263,Ercp sphincter pressure meas,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43270,Egd lesion ablation,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43275,Ercp remove forgn body duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43276,Ercp stent exchange w/dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43277,Ercp ea duct/ampulla dilate,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43279,Lap myotomy heller,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43280,Laparoscopy fundoplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43281,Lap paraesophag hern repair,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43282,Lap paraesoph her rpr w/mesh,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43283,Lap esoph lengthening,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43284,Laps esophgl sphnctr agmntj,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43285,Rmvl esophgl sphnctr dev,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43289,Laparoscope proc esoph,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43300,Repair of esophagus,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43305,Repair esophagus and fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43320,Fuse esophagus & stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43332,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43333,Transab esoph hiat hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43334,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43335,Transthor diaphrag hern rpr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43336,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43337,Thorabd diaphr hern repair,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43338,Esoph lengthening,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43401,Esophagus surgery for veins,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43410,Repair esophagus wound,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43420,Repair esophagus opening,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43450,Dilate esophagus 1/mult pass,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43453,Dilate esophagus,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43499,Esophagus surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43500,Surgical opening of stomach,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43510,Surgical opening of stomach,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43520,Incision of pyloric muscle,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43610,Excision of stomach lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43644,Lap gastric bypass/roux-en-y,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43645,Lap gastr bypass incl smll i,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43647,Lap impl electrode antrum,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43648,Lap revise/remv eltrd antrum,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43651,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43652,Laparoscopy vagus nerve,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43653,Laparoscopy gastrostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43659,Laparoscope proc stom,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43752,Nasal/orogastric w/tube plmt,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43753,Tx gastro intub w/asp,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43754,Dx gastr intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43755,Dx gastr intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43756,Dx duod intub w/asp spec,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43757,Dx duod intub w/asp specs,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43760,Change gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43761,Reposition gastrostomy tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43762,Rplc gtube no revj trc,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43763,Rplc gtube revj gstrst trc,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43770,Lap place gastr adj device,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43771,Lap revise gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43772,Lap rmvl gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43773,Lap replace gastr adj device,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43774,Lap rmvl gastr adj all parts,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43775,Lap sleeve gastrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43830,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43831,Place gastrostomy tube,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43832,Place gastrostomy tube,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43842,V-band gastroplasty,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43843,Gastroplasty w/o v-band,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43848,Revision gastroplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43860,Revise stomach-bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43870,Repair stomach opening,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43880,Repair stomach-bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43881,Impl/redo electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43882,Revise/remove electrd antrum,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43886,Revise gastric port open,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43887,Remove gastric port open,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43888,Change gastric port open,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,43999,Stomach surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44005,Freeing of bowel adhesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44015,Insert needle cath bowel,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44020,Explore small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44050,Reduce bowel obstruction,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44055,Correct malrotation of bowel,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44100,Biopsy of bowel,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44110,Excise intestine lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44111,Excision of bowel lesion(s),General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44125,Removal of small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44130,Bowel to bowel fusion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44139,Mobilization of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44141,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44143,Partial removal of colon,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44180,Lap enterolysis,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44186,Lap jejunostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44187,Lap ileo/jejuno-stomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44188,Lap colostomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44204,Laparo partial colectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44206,Lap part colectomy w/stoma,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44207,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44208,L colectomy/coloproctostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44213,Lap mobil splenic fl add-on,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44238,Laparoscope proc intestine,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44300,Open bowel to skin,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44312,Revision of ileostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44320,Colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44340,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44346,Revision of colostomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44360,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44361,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44363,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44364,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44365,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44366,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44369,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44370,Small bowel endoscopy/stent,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44372,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44373,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44376,Small bowel endoscopy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44377,Small bowel endoscopy/biopsy,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44378,Small bowel endoscopy,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44379,S bowel endoscope w/stent,Gastroenterology,Per Unit,$446.31 ,OP,$446.31 ,$446.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44380,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44381,Small bowel endoscopy br/wa,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44382,Small bowel endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44384,Small bowel endoscopy,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44385,Endoscopy of bowel pouch,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44386,Endoscopy bowel pouch/biop,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44388,Colonoscopy thru stoma spx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44389,Colonoscopy with biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44390,Colonoscopy for foreign body,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44391,Colonoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44392,Colonoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44394,Colonoscopy w/snare,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44401,Colonoscopy with ablation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44402,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44403,Colonoscopy w/resection,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44404,Colonoscopy w/injection,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44405,Colonoscopy w/dilation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44406,Colonoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44407,Colonoscopy w/ndl aspir/bx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44408,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44500,Intro gastrointestinal tube,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44602,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44603,Suture small intestine,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44615,Intestinal stricturoplasty,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44620,Repair bowel opening,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44640,Repair bowel-skin fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44650,Repair bowel fistula,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44799,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44800,Excision of bowel pouch,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44820,Excision of mesentery lesion,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44850,Repair of mesentery,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44899,Bowel surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44900,Drain appendix abscess open,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44950,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44955,Appendectomy add-on,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44960,Appendectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44970,Laparoscopy appendectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,44979,Laparoscope proc app,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45000,Drainage of pelvic abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45005,Drainage of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45020,Drainage of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45100,Biopsy of rectum,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45108,Removal of anorectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45113,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45123,Partial proctectomy,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45130,Excision of rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45136,Excise ileoanal reservior,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45150,Excision of rectal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45160,Excision of rectal lesion,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45171,Exc rect tum transanal part,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45172,Exc rect tum transanal full,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45190,Destruction rectal tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45300,Proctosigmoidoscopy dx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45303,Proctosigmoidoscopy dilate,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45305,Proctosigmoidoscopy w/bx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45307,Proctosigmoidoscopy fb,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45308,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45309,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45315,Proctosigmoidoscopy removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45317,Proctosigmoidoscopy bleed,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45320,Proctosigmoidoscopy ablate,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45321,Proctosigmoidoscopy volvul,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45327,Proctosigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45330,Diagnostic sigmoidoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45331,Sigmoidoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45332,Sigmoidoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45333,Sigmoidoscopy & polypectomy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45334,Sigmoidoscopy for bleeding,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45335,Sigmoidoscopy w/submuc inj,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45337,Sigmoidoscopy & decompress,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45338,Sigmoidoscopy w/tumr remove,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45340,Sig w/tndsc balloon dilation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45341,Sigmoidoscopy w/ultrasound,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45342,Sigmoidoscopy w/us guide bx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45346,Sigmoidoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45347,Sigmoidoscopy w/plcmt stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45349,Sigmoidoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45350,Sgmdsc w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45378,Diagnostic colonoscopy,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45379,Colonoscopy w/fb removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45380,Colonoscopy and biopsy,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45381,Colonoscopy submucous njx,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45382,Colonoscopy w/control bleed,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45384,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45385,Colonoscopy w/lesion removal,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45386,Colonoscopy w/balloon dilat,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45388,Colonoscopy w/ablation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45389,Colonoscopy w/stent plcmt,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45390,Colonoscopy w/resection,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45391,Colonoscopy w/endoscope us,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45392,Colonoscopy w/endoscopic fnb,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45393,Colonoscopy w/decompression,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45398,Colonoscopy w/band ligation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45399,Unlisted procedure colon,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45400,Laparoscopic proc,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45402,Lap proctopexy w/sig resect,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45499,Laparoscope proc rectum,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45500,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45505,Repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45520,Treatment of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45541,Correct rectal prolapse,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45560,Repair of rectocele,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45562,Exploration/repair of rectum,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45800,Repair rect/bladder fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45820,Repair rectourethral fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45900,Reduction of rectal prolapse,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45905,Dilation of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45910,Dilation of rectal narrowing,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45915,Remove rectal obstruction,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45990,Surg dx exam anorectal,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,45999,Rectum surgery procedure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46020,Placement of seton,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46030,Removal of rectal marker,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46040,Incision of rectal abscess,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46045,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46050,Incision of anal abscess,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46060,Incision of rectal abscess,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46070,Incision of anal septum,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46080,Incision of anal sphincter,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46083,Incise external hemorrhoid,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46200,Removal of anal fissure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46220,Excise anal ext tag/papilla,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46221,Ligation of hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46230,Removal of anal tags,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46250,Remove ext hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46255,Remove int/ext hem 1 group,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46257,Remove in/ex hem grp & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46258,Remove in/ex hem grp w/fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46260,Remove in/ex hem groups 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46261,Remove in/ex hem grps & fiss,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46262,Remove in/ex hem grps w/fist,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46270,Remove anal fist subq,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46275,Remove anal fist inter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46280,Remove anal fist complex,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46285,Remove anal fist 2 stage,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46288,Repair anal fistula,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46320,Removal of hemorrhoid clot,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46500,Injection into hemorrhoid(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46505,Chemodenervation anal musc,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46600,Diagnostic anoscopy spx,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46601,Diagnostic anoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46604,Anoscopy and dilation,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46606,Anoscopy and biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46607,Diagnostic anoscopy & biopsy,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46608,Anoscopy remove for body,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46610,Anoscopy remove lesion,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46611,Anoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46612,Anoscopy remove lesions,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46614,Anoscopy control bleeding,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46615,Anoscopy,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46700,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46705,Repair of anal stricture,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46706,Repr of anal fistula w/glue,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46707,Repair anorectal fist w/plug,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46710,Repr per/vag pouch sngl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46712,Repr per/vag pouch dbl proc,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46715,Rep perf anoper fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46716,Rep perf anoper/vestib fistu,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46740,Construction of absent anus,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46750,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46751,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46753,Reconstruction of anus,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46754,Removal of suture from anus,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46760,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46761,Repair of anal sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46762,Implant artificial sphincter,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46900,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46910,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46916,Cryosurgery anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46917,Laser surgery anal lesions,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46922,Excision of anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46924,Destruction anal lesion(s),General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46930,Destroy internal hemorrhoids,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46940,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46942,Treatment of anal fissure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46945,Int hrhc lig 1 hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46946,Int hrhc lig 2+hroid w/o img,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46947,Hemorrhoidopexy by stapling,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46948,Int hrhc tranal dartlzj 2+,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,46999,Anus surgery procedure,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47370,Laparo ablate liver tumor rf,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47371,Laparo ablate liver cryosurg,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47379,Laparoscope procedure liver,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47510,Insert catheter bile duct,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47511,Insert bile duct drain,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47525,Change bile duct catheter,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47530,Revise/reinsert bile tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47537,Removal biliary drg cath,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47560,Laparoscopy w/cholangio,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47561,Laparo w/cholangio/biopsy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47562,Laparoscopic cholecystectomy,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47563,Laparo cholecystectomy/graph,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47564,Laparo cholecystectomy/explr,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47570,Laparo cholecystoenterostomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47579,Laparoscope proc biliary,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,47630,Remove bile duct stone,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,48550,Donor pancreatectomy,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49000,Exploration of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49002,Reopening of abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49010,Exploration behind abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49203,Exc abd tum 5 cm or less,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49204,Exc abd tum over 5 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49205,Exc abd tum over 10 cm,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49215,Excise sacral spine tumor,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49220,Multiple surgery abdomen,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49250,Excision of umbilicus,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49255,Removal of omentum,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49320,Diag laparo separate proc,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49321,Laparoscopy biopsy,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49322,Laparoscopy aspiration,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49323,Laparo drain lymphocele,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49324,Lap insert tunnel ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49325,Lap revision perm ip cath,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49326,Lap w/omentopexy add-on,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49329,Laparo proc abdm/per/oment,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49402,Remove foreign body adbomen,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49425,Insert abdomen-venous drain,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49426,Revise abdomen-venous shunt,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49428,Ligation of shunt,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49429,Removal of shunt,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49440,Place gastrostomy tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49441,Place duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49442,Place cecostomy tube perc,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49446,Change g-tube to g-j perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49450,Replace g/c tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49451,Replace duod/jej tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49452,Replace g-j tube perc,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49460,Fix g/colon tube w/device,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49491,Rpr hern preemie reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49492,Rpr ing hern premie blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49495,Rpr ing hernia baby reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49496,Rpr ing hernia baby blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49500,Rpr ing hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49501,Rpr ing hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49505,Prp i/hern init reduc >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49507,Prp i/hern init block >5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49520,Rerepair ing hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49521,Rerepair ing hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49525,Repair ing hernia sliding,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49540,Repair lumbar hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49550,Rpr rem hernia init reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49553,Rpr fem hernia init blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49555,Rerepair fem hernia reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49557,Rerepair fem hernia blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49560,Rpr ventral hern init reduc,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49561,Rpr ventral hern init block,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49565,Rerepair ventrl hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49566,Rerepair ventrl hern block,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49568,Hernia repair w/mesh,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49570,Rpr epigastric hern reduce,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49572,Rpr epigastric hern blocked,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49580,Rpr umbil hern reduc < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49582,Rpr umbil hern block < 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49585,Rpr umbil hern reduc > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49587,Rpr umbil hern block > 5 yr,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49590,Repair spigelian hernia,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49600,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49606,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49610,Repair umbilical lesion,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49650,Lap ing hernia repair init,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49651,Lap ing hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49652,Lap vent/abd hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49653,Lap vent/abd hern proc comp,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49654,Lap inc hernia repair,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49655,Lap inc hern repair comp,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49656,Lap inc hernia repair recur,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49657,Lap inc hern recur comp,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49659,Laparo proc hernia repair,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49900,Repair of abdominal wall,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49904,Omental flap extra-abdom,General Surgery,Per Unit,"$2,599.18 ",OP,"$2,599.18 ","$2,599.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49905,Omental flap intra-abdom,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49906,Free omental flap microvasc,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,49999,Abdomen surgery procedure,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50389,Remove renal tube w/fluoro,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50390,Drainage of kidney lesion,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50391,Instll rx agnt into rnal tub,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50396,Measure kidney pressure,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50398,Change kidney tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50430,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50431,Njx px nfrosgrm &/urtrgrm,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50541,Laparo ablate renal cyst,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50542,Laparo ablate renal mass,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50543,Laparo partial nephrectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50544,Laparoscopy pyeloplasty,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50549,Laparoscope proc renal,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50945,Laparoscopy ureterolithotomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50947,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50948,Laparo new ureter/bladder,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,50949,Laparoscope proc ureter,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51100,Drain bladder by needle,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51500,Removal of bladder cyst,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51705,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51710,Change of bladder tube,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51715,Endoscopic injection/implant,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51720,Treatment of bladder lesion,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51725,Simple cystometrogram,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51726,Complex cystometrogram,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51727,Cystometrogram w/up,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51728,Cystometrogram w/vp,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51729,Cystometrogram w/vp&up,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51741,Electro-uroflowmetry first,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51784,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51785,Anal/urinary muscle study,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51792,Urinary reflex study,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51990,Laparo urethral suspension,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51992,Laparo sling operation,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,51999,Laparoscope proc bla,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52010,Cystoscopy & duct catheter,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52270,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52275,Cystoscopy & revise urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52276,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52277,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52282,Cystoscopy implant stent,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52283,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52285,Cystoscopy and treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52400,Cystouretero w/congen repr,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52402,Cystourethro cut ejacul duct,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52442,Cystourethro w/addl implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52601,Prostatectomy (turp),Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52630,Remove prostate regrowth,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52647,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52648,Laser surgery of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,52649,Prostate laser enucleation,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53000,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53010,Incision of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53020,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53025,Incision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53040,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53060,Drainage of urethra abscess,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53080,Drainage of urinary leakage,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53085,Drainage of urinary leakage,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53200,Biopsy of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53210,Removal of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53215,Removal of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53220,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53230,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53235,Removal of urethra lesion,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53240,Surgery for urethra pouch,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53250,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53260,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53265,Treatment of urethra lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53270,Removal of urethra gland,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53275,Repair of urethra defect,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53400,Revise urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53405,Revise urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53410,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53415,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53420,Reconstruct urethra stage 1,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53425,Reconstruct urethra stage 2,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53430,Reconstruction of urethra,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53431,Reconstruct urethra/bladder,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53440,Male sling procedure,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53442,Remove/revise male sling,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53444,Insert tandem cuff,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53446,Remove uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53448,Remov/replc ur sphinctr comp,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53449,Repair uro sphincter,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53450,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53460,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53500,Urethrlys transvag w/ scope,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53502,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53505,Repair of urethra injury,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53510,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53515,Repair of urethra injury,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53520,Repair of urethra defect,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53605,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53620,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53621,Dilate urethra stricture,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53665,Dilation of urethra,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53855,Insert prost urethral stent,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,53860,Transurethral rf treatment,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54000,Slitting of prepuce,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54001,Slitting of prepuce,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54015,Drain penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54050,Destruction penis lesion(s),Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54055,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54056,Cryosurgery penis lesion(s),Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54057,Laser surg penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54060,Excision of penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54065,Destruction penis lesion(s),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54100,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54105,Biopsy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54110,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54115,Treatment of penis lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54150,Circumcision w/regionl block,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54160,Circumcision neonate,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54161,Circum 28 days or older,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54162,Lysis penil circumic lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54163,Repair of circumcision,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54164,Frenulotomy of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54230,Prepare penis study,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54231,Dynamic cavernosometry,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54300,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54304,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54340,Secondary urethral surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54360,Penis plastic surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54380,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54385,Repair penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54400,Insert semi-rigid prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54401,Insert self-contd prosthesis,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54405,Insert multi-comp penis pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54406,Remove muti-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54408,Repair multi-comp penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54410,Remove/replace penis prosth,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54411,Remov/replc penis pros comp,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54415,Remove self-contd penis pros,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54416,Remv/repl penis contain pros,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54417,Remv/replc penis pros compl,Urological Surgery,Per Unit,"$6,916.67 ",OP,"$6,916.67 ","$6,916.67 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54420,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54430,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54435,Revision of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54440,Repair of penis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54450,Preputial stretching,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54500,Biopsy of testis,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54505,Biopsy of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54512,Excise lesion testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54520,Removal of testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54522,Orchiectomy partial,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54530,Removal of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54535,Extensive testis surgery,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54550,Exploration for testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54560,Exploration for testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54600,Reduce testis torsion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54620,Suspension of testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54640,Orchiopexy ingun/scrot appr,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54650,Orchiopexy (fowler-stephens),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54660,Revision of testis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54670,Repair testis injury,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54680,Relocation of testis(es),Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54690,Laparoscopy orchiectomy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54692,Laparoscopy orchiopexy,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54699,Laparoscope proc testis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54700,Drainage of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54800,Biopsy of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54830,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54840,Remove epididymis lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54860,Removal of epididymis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54861,Removal of epididymis,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54865,Explore epididymis,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54900,Fusion of spermatic ducts,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,54901,Fusion of spermatic ducts,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55040,Removal of hydrocele,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55041,Removal of hydroceles,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55060,Repair of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55100,Drainage of scrotum abscess,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55110,Explore scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55120,Removal of scrotum lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55150,Removal of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55175,Revision of scrotum,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55180,Revision of scrotum,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55200,Incision of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55250,Removal of sperm duct(s),Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55400,Repair of sperm duct,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55450,Ligation of sperm duct,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55500,Removal of hydrocele,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55520,Removal of sperm cord lesion,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55530,Revise spermatic cord veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55535,Revise spermatic cord veins,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55540,Revise hernia & sperm veins,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55550,Laparo ligate spermatic vein,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55559,Laparo proc spermatic cord,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55600,Incise sperm duct pouch,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55605,Incise sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55650,Remove sperm duct pouch,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55680,Remove sperm pouch lesion,Urological Surgery,Per Unit,"$1,364.21 ",OP,"$1,364.21 ","$1,364.21 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55801,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55810,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55815,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55821,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55831,Removal of prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55840,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55842,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55845,Extensive prostate surgery,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55860,Surgical exposure prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55866,Laparo radical prostatectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55870,Electroejaculation,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55873,Cryoablate prostate,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55874,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55880,Abltj mal prst8 tiss hifu,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,55899,Genital surgery procedure,Urological Surgery,Per Unit,$977.77 ,OP,$977.77 ,$977.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,56405,I & d of vulva/perineum,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,56420,Drainage of gland abscess,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,56820,Exam of vulva w/scope,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57150,Treat vagina infection,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57160,Insert pessary/other device,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57170,Fitting of diaphragm/cap,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57220,Revision of urethra,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57230,Repair of urethral lesion,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57240,Anterior colporrhaphy,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57250,Repair rectum & vagina,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57260,Cmbn ant pst colprhy,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57265,Cmbn ap colprhy w/ntrcl rpr,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57267,Insert mesh/pelvic flr addon,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57268,Repair of bowel bulge,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57270,Repair of bowel pouch,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57287,Revise/remove sling repair,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57288,Repair bladder defect,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57289,Repair bladder & vagina,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,57410,Pelvic examination,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,58300,Insert intrauterine device,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,58301,Remove intrauterine device,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,58321,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,58322,Artificial insemination,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,58323,Sperm washing,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,58970,Retrieval of oocyte,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,58974,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,58976,Transfer of embryo,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59020,Fetal contract stress test,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59025,Fetal non-stress test,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59030,Fetal scalp blood sample,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59050,Fetal monitor w/report,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59072,Umbilical cord occlud w/us,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59074,Fetal fluid drainage w/us,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59076,Fetal shunt placement w/us,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59400,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59409,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59410,Obstetrical care,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59610,Vbac delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59612,Vbac delivery only,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59614,Vbac care after delivery,Obstetrics,Per Unit,"$1,075.20 ",OP,"$1,075.20 ","$1,075.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59812,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59820,Care of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59821,Treatment of miscarriage,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59830,Treat uterus infection,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59840,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59841,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59850,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59851,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59852,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59855,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59856,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59857,Abortion,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59866,Abortion (mpr),Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,59897,Fetal invas px w/us,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,60000,Drain thyroid/tongue cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,60100,Biopsy of thyroid,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,60300,Aspir/inj thyroid cyst,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,60650,Laparoscopy adrenalectomy,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,60659,Laparo proc endocrine,General Surgery,Per Unit,"$1,656.92 ",OP,"$1,656.92 ","$1,656.92 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,60699,Endocrine surgery procedure,General Surgery,Per Unit,"$1,380.09 ",OP,"$1,380.09 ","$1,380.09 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61000,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61001,Remove cranial cavity fluid,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61020,Remove brain cavity fluid,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61026,Injection into brain canal,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61070,Brain canal shunt procedure,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61215,Insert brain-fluid device,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61623,Endovasc tempory vessel occl,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61624,Transcath occlusion cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61626,Transcath occlusion non-cns,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61630,Intracranial angioplasty,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61635,Intracran angioplsty w/stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61640,Dilate ic vasospasm init,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61641,Dilat ic vspsm ea vsl sm ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61642,Dilat ic vspsm ea diff ter,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61645,Perq art m-thrombect &/nfs,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61651,Evasc prlng admn rx agnt add,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61720,Incise skull/brain surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61770,Incise skull for treatment,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61790,Treat trigeminal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61791,Treat trigeminal tract,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61796,Srs cranial lesion simple,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61797,Srs cran les simple addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61798,Srs cranial lesion complex,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61799,Srs cran les complex addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61800,Apply srs headframe add-on,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61850,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61880,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61885,Insrt/redo neurostim 1 array,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61886,Implant neurostim arrays,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,61888,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62000,Treat skull fracture,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62194,Replace/irrigate catheter,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62225,Replace/irrigate catheter,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62230,Replace/revise brain shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62252,Csf shunt reprogram,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62292,Njx chemonucleolysis lmbr,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62302,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62303,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62304,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62305,Myelography lumbar injection,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62310,Inject spine cerv/thoracic,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62311,Inject spine lumbar/sacral,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62318,Inject spine w/cath crv/thrc,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62319,Inject spine w/cath lmb/scrl,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62350,Implant spinal canal cath,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62355,Remove spinal canal catheter,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62360,Insert spine infusion device,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62361,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62362,Implant spine infusion pump,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62365,Remove spine infusion device,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62367,Analyze spine infus pump,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62368,Analyze sp inf pump w/reprog,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62369,Anal sp inf pmp w/reprg&fill,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,62370,Anl sp inf pmp w/mdreprg&fil,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63600,Remove spinal cord lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63610,Stimulation of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63615,Remove lesion of spinal cord,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63620,Srs spinal lesion,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63621,Srs spinal lesion addl,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63650,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63661,Remove spine eltrd perq aray,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63662,Remove spine eltrd plate,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63663,Revise spine eltrd perq aray,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63664,Revise spine eltrd plate,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63685,Insrt/redo spine n generator,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63688,Revise/remove neuroreceiver,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63707,Repair spinal fluid leakage,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63741,Install spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63744,Revision of spinal shunt,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,63746,Removal of spinal shunt,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64400,Njx aa&/strd trigeminal nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64402,N block inj facial,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64405,Njx aa&/strd gr ocpl nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64408,Njx aa&/strd vagus nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64410,N block inj phrenic,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64412,N block inj spinal accessor,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64413,N block inj cervical plexus,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64415,Njx aa&/strd brach plexus,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64416,Njx aa&/strd brach plex nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64417,Njx aa&/strd axillary nrv,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64418,Njx aa&/strd sprscap nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64420,Njx aa&/strd ntrcost nrv 1,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64421,Njx aa&/strd ntrcost nrv ea,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64425,Njx aa&/strd ii ih nerves,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64430,Njx aa&/strd pudendal nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64435,Njx aa&/strd paracrv nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64445,Njx aa&/strd sciatic nerve,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64446,Njx aa&/strd sciatic nrv nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64447,Njx aa&/strd femoral nerve,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64448,Njx aa&/strd fem nerve nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64449,Njx aa&/strd lmbr plex nfs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64450,Njx aa&/strd other pn/branch,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64454,Njx aa&/strd gnclr nrv brnch,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64455,Njx aa&/strd pltr com dg nrv,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64486,Tap block unil by injection,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64487,Tap block uni by infusion,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64488,Tap block bi injection,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64489,Tap block bi by infusion,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64505,N block spenopalatine gangl,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64508,N block carotid sinus s/p,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64510,N block stellate ganglion,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64517,N block inj hypogas plxs,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64530,N block inj celiac pelus,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64550,Appl surface neurostimulator,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64553,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64555,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64561,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64565,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64566,Neuroeltrd stim post tibial,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64568,Inc for vagus n elect impl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64569,Revise/repl vagus n eltrd,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64570,Remove vagus n eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64575,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64580,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64581,Implant neuroelectrodes,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64585,Revise/remove neuroelectrode,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64590,Insrt/redo pn/gastr stimul,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64595,Revise/rmv pn/gastr stimul,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64600,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64605,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64610,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64611,Chemodenerv saliv glands,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64612,Destroy nerve face muscle,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64615,Chemodenerv musc migraine,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64616,Chemodenerv musc neck dyston,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64617,Chemodener muscle larynx emg,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64620,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64624,Dstrj nulyt agt gnclr nrv,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64625,Rf abltj nrv nrvtg si jt,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64630,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64632,N block inj common digit,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64640,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64642,Chemodenerv 1 extremity 1-4,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64643,Chemodenerv 1 extrem 1-4 ea,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64644,Chemodenerv 1 extrem 5/> mus,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64645,Chemodenerv 1 extrem 5/> ea,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64646,Chemodenerv trunk musc 1-5,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64647,Chemodenerv trunk musc 6/>,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64650,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64653,Chemodenerv eccrine glands,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64680,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64681,Injection treatment of nerve,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64702,Revise finger/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64704,Revise hand/foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64708,Revise arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64712,Revision of sciatic nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64713,Revision of arm nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64714,Revise low back nerve(s),Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64716,Revision of cranial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64718,Revise ulnar nerve at elbow,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64719,Revise ulnar nerve at wrist,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64721,Carpal tunnel surgery,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64722,Relieve pressure on nerve(s),Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64726,Release foot/toe nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64727,Internal nerve revision,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64732,Incision of brow nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64734,Incision of cheek nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64736,Incision of chin nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64738,Incision of jaw nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64740,Incision of tongue nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64742,Incision of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64744,Incise nerve back of head,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64746,Incise diaphragm nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64763,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64766,Incise hip/thigh nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64771,Sever cranial nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64772,Incision of spinal nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64774,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64776,Remove digit nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64778,Digit nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64782,Remove limb nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64783,Limb nerve surgery add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64784,Remove nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64786,Remove sciatic nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64787,Implant nerve end,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64788,Remove skin nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64790,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64792,Removal of nerve lesion,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64795,Biopsy of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64802,Sympathectomy cervical,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64804,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64818,Remove sympathetic nerves,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64820,Sympathectomy digital artery,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64821,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64822,Remove sympathetic nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64823,Sympathectomy supfc palmar,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64831,Repair of digit nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64832,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64834,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64835,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64836,Repair of hand or foot nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64837,Repair nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64840,Repair of leg nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64856,Repair/transpose nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64857,Repair arm/leg nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64858,Repair sciatic nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64859,Nerve surgery,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64861,Repair of arm nerves,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64862,Repair of low back nerves,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64864,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64865,Repair of facial nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64866,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64868,Fusion of facial/other nerve,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64872,Subsequent repair of nerve,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64874,Repair & revise nerve add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64876,Repair nerve/shorten bone,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64885,Nerve graft head/neck 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64886,Nerve graft head/neck >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64890,Nerve graft hand/foot 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64891,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64892,Nerve graft arm/leg <4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64893,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64895,Nerve graft hand/foot 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64896,Nerve graft hand/foot >4 cm,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64897,Nerve graft arm/leg 4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64898,Nerve graft arm/leg >4 cm,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64901,Nerve graft add-on,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64902,Nerve graft add-on,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64905,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64907,Nerve pedicle transfer,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64910,Nerve repair w/allograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64911,Neurorraphy w/vein autograft,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64912,Nrv rpr w/nrv algrft 1st,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64913,Nrv rpr w/nrv algrft ea addl,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,64999,Nervous system surgery,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65091,Revise eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65093,Revise eye with implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65101,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65103,Remove eye/insert implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65105,Remove eye/attach implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65110,Removal of eye,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65112,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65114,Remove eye/revise socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65125,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65130,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65135,Insert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65140,Attach ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65150,Revise ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65155,Reinsert ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65175,Removal of ocular implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65205,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65210,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65220,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65222,Remove foreign body from eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65235,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65260,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65265,Remove foreign body from eye,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65270,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65272,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65275,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65280,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65285,Repair of eye wound,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65286,Repair of eye wound,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65290,Repair of eye socket wound,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65400,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65410,Biopsy of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65420,Removal of eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65426,Removal of eye lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65430,Corneal smear,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65435,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65436,Curette/treat cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65450,Treatment of corneal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65600,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65710,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65730,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65750,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65755,Corneal transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65756,Corneal trnspl endothelial,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65757,Prep corneal endo allograft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65760,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65765,Revision of cornea,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65767,Corneal tissue transplant,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65770,Revise cornea with implant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65771,Radial keratotomy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65772,Correction of astigmatism,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65775,Correction of astigmatism,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65778,Cover eye w/membrane,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65779,Cover eye w/membrane suture,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65780,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65781,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65782,Ocular reconst transplant,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65785,Impltj ntrstrml crnl rng seg,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65800,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65810,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65815,Drainage of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65820,Relieve inner eye pressure,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65850,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65855,Trabeculoplasty laser surg,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65860,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65865,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65870,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65875,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65880,Incise inner eye adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65900,Remove eye lesion,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65920,Remove implant of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,65930,Remove blood clot from eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66020,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66030,Injection treatment of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66130,Remove eye lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66150,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66155,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66160,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66170,Glaucoma surgery,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66172,Incision of eye,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66174,Translum dil eye canal,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66175,Trnslum dil eye canal w/stnt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66179,Aqueous shunt eye w/o graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66180,Aqueous shunt eye w/graft,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66183,Insert ant drainage device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66184,Revision of aqueous shunt,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66185,Revise aqueous shunt eye,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66220,Repair eye lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66225,Repair/graft eye lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66250,Follow-up surgery of eye,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66500,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66505,Incision of iris,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66600,Remove iris and lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66605,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66625,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66630,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66635,Removal of iris,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66680,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66682,Repair iris & ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66700,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66710,Ciliary transsleral therapy,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66711,Ecp ciliary body destruction,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66720,Destruction ciliary body,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66740,Destruction ciliary body,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66761,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66762,Revision of iris,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66770,Removal of inner eye lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66820,Incision secondary cataract,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66821,After cataract laser surgery,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66825,Reposition intraocular lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66830,Removal of lens lesion,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66840,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66850,Removal of lens material,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66852,Removal of lens material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66920,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66930,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66940,Extraction of lens,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66982,Xcapsl ctrc rmvl cplx wo ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66983,Cataract surg w/iol 1 stage,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66984,Xcapsl ctrc rmvl w/o ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66985,Insert lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66986,Exchange lens prosthesis,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66987,Xcapsl ctrc rmvl cplx w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66988,Xcapsl ctrc rmvl w/ecp,Ophthalmology Surgery,Per Unit,$925.52 ,OP,$925.52 ,$925.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,66999,Eye surgery procedure,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67005,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67010,Partial removal of eye fluid,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67015,Release of eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67025,Replace eye fluid,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67027,Implant eye drug system,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67028,Injection eye drug,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67030,Incise inner eye strands,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67031,Laser surgery eye strands,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67036,Removal of inner eye fluid,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67039,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67040,Laser treatment of retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67041,Vit for macular pucker,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67042,Vit for macular hole,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67043,Vit for membrane dissect,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67101,Repair detached retina crtx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67105,Repair detached retina pc,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67107,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67108,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67110,Repair detached retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67112,Rerepair detached retina,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67113,Repair retinal detach cplx,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67115,Release encircling material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67120,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67121,Remove eye implant material,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67141,Treatment of retina,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67145,Treatment of retina,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67208,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67210,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67218,Treatment of retinal lesion,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67220,Treatment of choroid lesion,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67221,Ocular photodynamic ther,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67225,Eye photodynamic ther add-on,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67227,Dstrj extensive retinopathy,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67228,Treatment x10sv retinopathy,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67229,Tr retinal les preterm inf,Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67250,Reinforce eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67255,Reinforce/graft eye wall,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67299,Eye surgery procedure,Ophthalmology Surgery,Per Unit,"$1,212.94 ",OP,"$1,212.94 ","$1,212.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67311,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67312,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67314,Revise eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67316,Revise two eye muscles,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67318,Revise eye muscle(s),Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67320,Revise eye muscle(s) add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67331,Eye surgery follow-up add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67332,Rerevise eye muscles add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67334,Revise eye muscle w/suture,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67335,Eye suture during surgery,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67340,Revise eye muscle add-on,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67343,Release eye tissue,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67345,Destroy nerve of eye muscle,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67346,Biopsy eye muscle,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67399,Unlisted px extraocular musc,Ophthalmology Surgery,Per Unit,"$1,086.25 ",OP,"$1,086.25 ","$1,086.25 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67400,Explore/biopsy eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67405,Explore/drain eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67412,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67413,Explore/treat eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67414,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67415,Aspiration orbital contents,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67445,Explr/decompress eye socket,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67500,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67505,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67515,Inject/treat eye socket,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67550,Insert eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67560,Revise eye socket implant,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67570,Decompress optic nerve,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67599,Orbit surgery procedure,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67700,Drainage of eyelid abscess,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67710,Incision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67715,Incision of eyelid fold,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67800,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67801,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67805,Remove eyelid lesions,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67808,Remove eyelid lesion(s),Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67810,Biopsy eyelid & lid margin,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67820,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67825,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67830,Revise eyelashes,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67835,Revise eyelashes,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67840,Remove eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67850,Treat eyelid lesion,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67875,Closure of eyelid by suture,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67880,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67882,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67900,Repair brow defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67901,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67902,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67903,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67904,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67906,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67908,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67909,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67911,Revise eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67912,Correction eyelid w/implant,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67914,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67915,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67916,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67917,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67921,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67922,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67923,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67924,Repair eyelid defect,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67930,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67935,Repair eyelid wound,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67938,Remove eyelid foreign body,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67950,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67961,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67966,Revision of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67971,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67973,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67974,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67975,Reconstruction of eyelid,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,67999,Revision of eyelid,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68020,Incise/drain eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68040,Treatment of eyelid lesions,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68100,Biopsy of eyelid lining,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68110,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68115,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68130,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68135,Remove eyelid lining lesion,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68200,Treat eyelid by injection,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68320,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68325,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68326,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68328,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68330,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68335,Revise/graft eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68340,Separate eyelid adhesions,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68360,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68362,Revise eyelid lining,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68371,Harvest eye tissue alograft,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68399,Eyelid lining surgery,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68400,Incise/drain tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68420,Incise/drain tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68440,Incise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68500,Removal of tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68505,Partial removal tear gland,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68510,Biopsy of tear gland,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68520,Removal of tear sac,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68525,Biopsy of tear sac,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68530,Clearance of tear duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68540,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68550,Remove tear gland lesion,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68700,Repair tear ducts,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68705,Revise tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68720,Create tear sac drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68745,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68750,Create tear duct drain,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68760,Close tear duct opening,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68761,Close tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68770,Close tear system fistula,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68801,Dilate tear duct opening,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68810,Probe nasolacrimal duct,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68811,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68815,Probe nasolacrimal duct,Ophthalmology Surgery,Per Unit,$925.56 ,OP,$925.56 ,$925.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68816,Probe nl duct w/balloon,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68840,Explore/irrigate tear ducts,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,68899,Tear duct system surgery,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69005,Drain external ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69100,Biopsy of external ear,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69105,Biopsy of external ear canal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69110,Remove external ear partial,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69120,Removal of external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69140,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69145,Remove ear canal lesion(s),Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69150,Extensive ear canal surgery,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69155,Extensive ear/neck surgery,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69205,Clear outer ear canal,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69222,Clean out mastoid cavity,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69300,Revise external ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69310,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69320,Rebuild outer ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69399,Outer ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69421,Incision of eardrum,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69424,Remove ventilating tube,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69433,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69436,Create eardrum opening,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69440,Exploration of middle ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69450,Eardrum revision,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69501,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69502,Mastoidectomy,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69505,Remove mastoid structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69511,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69530,Extensive mastoid surgery,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69540,Remove ear lesion,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69550,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69552,Remove ear lesion,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69601,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69602,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69603,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69604,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69605,Mastoid surgery revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69610,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69620,Repair of eardrum,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69631,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69632,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69633,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69635,Repair eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69636,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69637,Rebuild eardrum structures,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69641,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69642,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69643,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69644,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69645,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69646,Revise middle ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69650,Release middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69660,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69661,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69662,Revise middle ear bone,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69666,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69667,Repair middle ear structures,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69670,Remove mastoid air cells,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69676,Remove middle ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69700,Close mastoid fistula,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69705,Nps surg dilat eust tube uni,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69706,Nps surg dilat eust tube bi,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69710,Implant/replace hearing aid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69711,Remove/repair hearing aid,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69714,Implant temple bone w/stimul,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69715,Temple bne implnt w/stimulat,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69717,Temple bone implant revision,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69718,Revise temple bone implant,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69720,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69725,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69740,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69745,Repair facial nerve,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69799,Middle ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69801,Incise inner ear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69805,Explore inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69806,Explore inner ear,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69820,Establish inner ear window,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69840,Revise inner ear window,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69905,Remove inner ear,Otolaryngology Surgery,Per Unit,"$1,520.70 ",OP,"$1,520.70 ","$1,520.70 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69910,Remove inner ear & mastoid,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69915,Incise inner ear nerve,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69930,Implant cochlear device,Otolaryngology Surgery,Per Unit,"$15,529.51 ",OP,"$15,529.51 ","$15,529.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69949,Inner ear surgery procedure,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69955,Release facial nerve,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,69960,Release inner ear canal,Otolaryngology Surgery,Per Unit,"$2,241.51 ",OP,"$2,241.51 ","$2,241.51 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70010,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70015,Contrast x-ray of brain,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70030,X-ray eye for foreign body,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70100,X-ray exam of jaw <4views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70110,X-ray exam of jaw 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70120,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70130,X-ray exam of mastoids,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70134,X-ray exam of middle ear,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70140,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70150,X-ray exam of facial bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70160,X-ray exam of nasal bones,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70190,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70200,X-ray exam of eye sockets,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70210,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70220,X-ray exam of sinuses,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70240,X-ray exam pituitary saddle,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70250,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70260,X-ray exam of skull,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70300,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70310,X-ray exam of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70320,Full mouth x-ray of teeth,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70328,X-ray exam of jaw joint,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70330,X-ray exam of jaw joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70336,Magnetic image jaw joint,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70350,X-ray head for orthodontia,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70355,Panoramic x-ray of jaws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70360,X-ray exam of neck,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70370,Throat x-ray & fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70373,Contrast x-ray of larynx,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70380,X-ray exam of salivary gland,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70450,Ct head/brain w/o dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70460,Ct head/brain w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70470,Ct head/brain w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70480,Ct orbit/ear/fossa w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70481,Ct orbit/ear/fossa w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70482,Ct orbit/ear/fossa w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70486,Ct maxillofacial w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70487,Ct maxillofacial w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70488,Ct maxillofacial w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70490,Ct soft tissue neck w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70491,Ct soft tissue neck w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70492,Ct sft tsue nck w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70496,Ct angiography head,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70498,Ct angiography neck,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70540,Mri orbit/face/neck w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70542,Mri orbit/face/neck w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70543,Mri orbt/fac/nck w/o &w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70544,Mr angiography head w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70545,Mr angiography head w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70546,Mr angiograph head w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70547,Mr angiography neck w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70548,Mr angiography neck w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70549,Mr angiograph neck w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70551,Mri brain stem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70552,Mri brain stem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70553,Mri brain stem w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70554,Fmri brain by tech,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70555,Fmri brain by phys/psych,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70557,Mri brain w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70558,Mri brain w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,70559,Mri brain w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71010,Chest x-ray 1 view frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71015,Chest x-ray stereo frontal,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71020,Chest x-ray 2vw frontal&latl,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71021,Chest x-ray frnt lat lordotc,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71022,Chest x-ray frnt lat oblique,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71023,Chest x-ray and fluoroscopy,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71030,Chest x-ray 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71034,Chest x-ray&fluoro 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71035,Chest x-ray special views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71045,X-ray exam chest 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71046,X-ray exam chest 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71047,X-ray exam chest 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71048,X-ray exam chest 4+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71100,X-ray exam ribs uni 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71101,X-ray exam unilat ribs/chest,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71110,X-ray exam ribs bil 3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71111,X-ray exam ribs/chest4/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71120,X-ray exam breastbone 2/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71130,X-ray strenoclavic jt 3/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71250,Ct thorax dx c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71260,Ct thorax dx c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71270,Ct thorax dx c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71271,Ct thorax lung cancer scr c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71275,Ct angiography chest,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71550,Mri chest w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71551,Mri chest w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71552,Mri chest w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,71555,Mri angio chest w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72010,X-ray exam spine ap&lat,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72020,X-ray exam of spine 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72040,X-ray exam neck spine 2-3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72050,X-ray exam neck spine 4/5vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72052,X-ray exam neck spine 6/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72069,X-ray exam trunk spine stand,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72070,X-ray exam thorac spine 2vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72072,X-ray exam thorac spine 3vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72074,X-ray exam thorac spine4/>vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72080,X-ray exam thoracolmb 2/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72081,X-ray exam entire spi 1 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72082,X-ray exam entire spi 2/3 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72083,X-ray exam entire spi 4/5 vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72084,X-ray exam entire spi 6/> vw,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72090,X-ray exam scloiosis erect,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72100,X-ray exam l-s spine 2/3 vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72110,X-ray exam l-2 spine 4/>vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72114,X-ray exam l-s spine bending,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72120,X-ray bend only l-s spine,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72125,Ct neck spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72126,Ct neck spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72127,Ct neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72128,Ct chest spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72129,Ct chest spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72130,Ct chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72131,Ct lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72132,Ct lumbar spine w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72133,Ct lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72141,Mri neck spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72142,Mri neck spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72146,Mri chest spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72147,Mri chest spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72148,Mri lumbar spine w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72149,Mri lumbar spine w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72156,Mri neck spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72157,Mri chest spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72158,Mri lumbar spine w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72159,Mr angio spine w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72170,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72190,X-ray exam of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72191,Ct angiograph pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72192,Ct pelvis w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72193,Ct pelvis w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72194,Ct pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72195,Mri pelvis w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72196,Mri pelvis w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72197,Mri pelvis w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72198,Mr angio pelvis w/o & w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72200,X-ray exam si joints,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72202,X-ray exam si joints 3/> vws,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72220,X-ray exam sacrum tailbone,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72240,Myelography neck spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72255,Myelography thoracic spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72265,Myelography l-s spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72270,Myelogphy 2/> spine regions,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72275,Epidurography,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72285,Discography cerv/thor spine,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,72295,X-ray of lower spine disk,Diagnostic Radiology,Per Unit,$345.35 ,OP,$345.35 ,$345.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73000,X-ray exam of collar bone,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73010,X-ray exam of shoulder blade,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73020,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73030,X-ray exam of shoulder,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73050,X-ray exam of shoulders,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73060,X-ray exam of humerus,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73070,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73080,X-ray exam of elbow,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73090,X-ray exam of forearm,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73092,X-ray exam of arm infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73100,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73110,X-ray exam of wrist,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73120,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73130,X-ray exam of hand,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73140,X-ray exam of finger(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73200,Ct upper extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73201,Ct upper extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73202,Ct uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73206,Ct angio upr extrm w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73218,Mri upper extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73219,Mri upper extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73220,Mri uppr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73221,Mri joint upr extrem w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73222,Mri joint upr extrem w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73223,Mri joint upr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73225,Mr angio upr extr w/o&w/dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73500,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73501,X-ray exam hip uni 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73502,X-ray exam hip uni 2-3 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73503,X-ray exam hip uni 4/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73510,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73520,X-ray exam of hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73521,X-ray exam hips bi 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73522,X-ray exam hips bi 3-4 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73523,X-ray exam hips bi 5/> views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73530,X-ray exam of hip,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73540,X-ray exam of pelvis & hips,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73550,X-ray exam of thigh,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73551,X-ray exam of femur 1,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73552,X-ray exam of femur 2/>,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73560,X-ray exam of knee 1 or 2,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73562,X-ray exam of knee 3,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73564,X-ray exam knee 4 or more,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73565,X-ray exam of knees,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73590,X-ray exam of lower leg,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73592,X-ray exam of leg infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73600,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73610,X-ray exam of ankle,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73620,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73630,X-ray exam of foot,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73650,X-ray exam of heel,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73660,X-ray exam of toe(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73700,Ct lower extremity w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73701,Ct lower extremity w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73702,Ct lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73706,Ct angio lwr extr w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73718,Mri lower extremity w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73719,Mri lower extremity w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73720,Mri lwr extremity w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73721,Mri jnt of lwr extre w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73722,Mri joint of lwr extr w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73723,Mri joint lwr extr w/o&w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,73725,Mr ang lwr ext w or w/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74000,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74010,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74018,X-ray exam abdomen 1 view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74019,X-ray exam abdomen 2 views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74020,X-ray exam of abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74021,X-ray exam abdomen 3+ views,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74022,X-ray exam complete abdomen,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74150,Ct abdomen w/o dye,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74160,Ct abdomen w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74170,Ct abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74174,Ct angio abd&pelv w/o&w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74175,Ct angio abdom w/o & w/dye,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74176,Ct abd & pelvis w/o contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74177,Ct abd & pelv w/contrast,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74178,Ct abd & pelv 1/> regns,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74181,Mri abdomen w/o dye,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74182,Mri abdomen w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74183,Mri abdomen w/o & w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74185,Mri angio abdom w orw/o dye,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74210,X-ray xm phrnx&/crv esoph c+,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74220,X-ray xm esophagus 1cntrst,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74235,Remove esophagus obstruction,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74261,Ct colonography dx,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74262,Ct colonography dx w/dye,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74263,Ct colonography screening,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74300,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74301,X-rays at surgery add-on,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74305,X-ray bile ducts/pancreas,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74320,Contrast x-ray of bile ducts,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74327,X-ray bile stone removal,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74328,X-ray bile duct endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74329,X-ray for pancreas endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74330,X-ray bile/panc endoscopy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74340,X-ray guide for gi tube,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74355,X-ray guide intestinal tube,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74360,X-ray guide gi dilation,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74363,X-ray bile duct dilation,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74475,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74480,X-ray control cath insert,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74485,Dilation urtr/urt rs&i,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74710,X-ray measurement of pelvis,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74712,Mri fetal sngl/1st gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74713,Mri fetal ea addl gestation,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,74742,X-ray fallopian tube,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75557,Cardiac mri for morph,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75559,Cardiac mri w/stress img,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75561,Cardiac mri for morph w/dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75563,Card mri w/stress img & dye,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75565,Card mri veloc flow mapping,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75571,Ct hrt w/o dye w/ca test,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75572,Ct hrt w/3d image,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75573,Ct hrt w/3d image congen,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75574,Ct angio hrt w/3d image,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75605,Contrast exam thoracic aorta,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75635,Ct angio abdominal arteries,Interventional Radiology,Per Unit,$178.94 ,OP,$178.94 ,$178.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75705,Artery x-rays spine,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75726,Artery x-rays abdomen,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75736,Artery x-rays pelvis,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75774,Artery x-ray each vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75791,Av dialysis shunt imaging,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75842,Vein x-ray adrenal glands,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75893,Venous sampling by catheter,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75894,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75896,X-rays transcath therapy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75901,Remove cva device obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75902,Remove cva lumen obstruct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75945,Intravascular us,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75946,Intravascular us add-on,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75952,Endovasc repair abdom aorta,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75953,Abdom aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75954,Iliac aneurysm endovas rpr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75956,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75957,Xray endovasc thor ao repr,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75958,Xray place prox ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75959,Xray place dist ext thor ao,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75962,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75964,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75966,Repair arterial blockage,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75968,Repair artery blockage each,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75970,Vascular biopsy,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75980,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75982,Contrast xray exam bile duct,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75984,Xray control catheter change,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,75989,Abscess drainage under x-ray,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76010,X-ray nose to rectum,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76100,X-ray exam of body section,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76101,Complex body section x-ray,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76102,Complex body section x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76120,Cine/video x-rays,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76125,Cine/video x-rays add-on,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76145,Med physic dos eval rad exps,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76380,Cat scan follow-up study,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76390,Mr spectroscopy,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76391,Mr elastography,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76496,Fluoroscopic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76497,Ct procedure,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76498,Mri procedure,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76499,Radiographic procedure,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76506,Echo exam of head,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76510,Oph us dx b-scan&quan a-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76511,Oph us dx quan a-scan only,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76512,Oph us dx b-scan,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76513,Oph us dx ant sgm us uni/bi,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76514,Echo exam of eye thickness,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76516,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76519,Echo exam of eye,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76529,Echo exam of eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76536,Us exam of head and neck,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76604,Us exam chest,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76641,Ultrasound breast complete,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76642,Ultrasound breast limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76700,Us exam abdom complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76705,Echo exam of abdomen,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76706,Us abdl aorta screen aaa,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76770,Us exam abdo back wall comp,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76775,Us exam abdo back wall lim,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76776,Us exam k transpl w/doppler,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76800,Us exam spinal canal,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76801,Ob us < 14 wks single fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76802,Ob us < 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76805,Ob us >= 14 wks sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76810,Ob us >= 14 wks addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76811,Ob us detailed sngl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76812,Ob us detailed addl fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76813,Ob us nuchal meas 1 gest,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76814,Ob us nuchal meas add-on,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76815,Ob us limited fetus(s),Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76816,Ob us follow-up per fetus,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76817,Transvaginal us obstetric,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76818,Fetal biophys profile w/nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76819,Fetal biophys profil w/o nst,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76820,Umbilical artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76821,Middle cerebral artery echo,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76825,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76826,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76827,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76828,Echo exam of fetal heart,Diagnostic Radiology,Per Unit,$56.13 ,OP,$56.13 ,$56.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76830,Transvaginal us non-ob,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76831,Echo exam uterus,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76856,Us exam pelvic complete,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76857,Us exam pelvic limited,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76870,Us exam scrotum,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76872,Us transrectal,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76873,Echograp trans r pros study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76881,Us compl joint r-t w/img,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76882,Us lmtd jt/nonvasc xtr strux,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76885,Us exam infant hips dynamic,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76886,Us exam infant hips static,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76930,Echo guide cardiocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76932,Echo guide for heart biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76936,Echo guide for artery repair,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76937,Us guide vascular access,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76940,Us guide tissue ablation,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76941,Echo guide for transfusion,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76942,Echo guide for biopsy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76945,Echo guide villus sampling,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76946,Echo guide for amniocentesis,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76948,Echo guide ova aspiration,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76965,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76970,Ultrasound exam follow-up,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76975,Gi endoscopic ultrasound,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76977,Us bone density measure,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76978,Us trgt dyn mbubb 1st les,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76979,Us trgt dyn mbubb ea addl,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76981,Use parenchyma,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76982,Use 1st target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76983,Use ea addl target lesion,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76998,Us guide intraop,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,76999,Echo examination procedure,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77001,Fluoroguide for vein device,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77002,Needle localization by xray,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77003,Fluoroguide for spine inject,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77011,Ct scan for localization,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77012,Ct scan for needle biopsy,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77013,Ct guide for tissue ablation,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77014,Ct scan for therapy guide,Interventional Radiology,Per Unit,$61.07 ,OP,$61.07 ,$61.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77021,Mri guidance ndl plmt rs&i,Interventional Radiology,Per Unit,$108.13 ,OP,$108.13 ,$108.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77022,Mri gdn parnchyma tiss abltj,Interventional Radiology,Per Unit,$108.13 ,OP,$108.13 ,$108.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77046,Mri breast c- unilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77047,Mri breast c- bilateral,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77048,Mri breast c-+ w/cad uni,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77049,Mri breast c-+ w/cad bi,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77055,Mammogram one breast,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77056,Mammogram both breasts,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77057,Mammogram screening,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77058,Mri one breast,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77059,Mri both breasts,Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77061,Breast tomosynthesis uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77062,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77063,Breast tomosynthesis bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77065,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77066,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77067,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77072,X-rays for bone age,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77073,X-rays bone length studies,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77074,X-rays bone survey limited,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77076,X-rays bone survey infant,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77077,Joint survey single view,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77078,Ct bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77080,Dxa bone density axial,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77081,Dxa bone density/peripheral,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77084,Magnetic image bone marrow,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77085,Dxa bone density study,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77086,Fracture assessment via dxa,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77261,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77262,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77263,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77280,Set radiation therapy field,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77285,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77290,Set radiation therapy field,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77293,Respirator motion mgmt simul,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77295,3-d radiotherapy plan,Therapeutic Radiology,Per Unit,$68.45 ,OP,$68.45 ,$68.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77299,Radiation therapy planning,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77300,Radiation therapy dose plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77301,Radiotherapy dose plan imrt,Therapeutic Radiology,Per Unit,$68.45 ,OP,$68.45 ,$68.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77306,Telethx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77307,Telethx isodose plan cplx,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77316,Brachytx isodose plan simple,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77317,Brachytx isodose intermed,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77318,Brachytx isodose complex,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77321,Special teletx port plan,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77331,Special radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77332,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77333,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77334,Radiation treatment aid(s),Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77336,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77338,Design mlc device for imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77370,Radiation physics consult,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77371,Srs multisource,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77372,Srs linear based,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77373,Sbrt delivery,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77385,Ntsty modul rad tx dlvr smpl,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77386,Ntsty modul rad tx dlvr cplx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77387,Guidance for radj tx dlvr,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77399,External radiation dosimetry,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77401,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77402,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77407,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77412,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77417,Radiology port images(s),Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77422,Neutron beam tx simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77423,Neutron beam tx complex,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77424,Io rad tx delivery by x-ray,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77425,Io rad tx deliver by elctrns,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77427,Radiation tx management x5,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77431,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77432,Stereotactic radiation trmt,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77435,Sbrt management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77469,Io radiation tx management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77470,Special radiation treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77499,Radiation therapy management,Therapeutic Radiology,Per Unit,$70.25 ,OP,$70.25 ,$70.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77520,Proton trmt simple w/o comp,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77522,Proton trmt simple w/comp,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77523,Proton trmt intermediate,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77525,Proton treatment complex,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77600,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77605,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77610,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77615,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77620,Hyperthermia treatment,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77750,Infuse radioactive materials,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77761,Apply intrcav radiat simple,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77762,Apply intrcav radiat interm,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77763,Apply intrcav radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77767,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77768,Hdr rdncl skn surf brachytx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77770,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77771,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77772,Hdr rdncl ntrstl/icav brchtx,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77776,Apply interstit radiat simpl,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77777,Apply interstit radiat inter,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77778,Apply interstit radiat compl,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77785,Hdr brachytx 1 channel,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77786,Hdr brachytx 2-12 channel,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77787,Hdr brachytx over 12 chan,Therapeutic Radiology,Per Unit,"$1,627.76 ",OP,"$1,627.76 ","$1,627.76 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77789,Apply surf ldr radionuclide,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77790,Radiation handling,Therapeutic Radiology,Per Unit,$194.79 ,OP,$194.79 ,$194.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,77799,Radium/radioisotope therapy,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78012,Thyroid uptake measurement,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78013,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78014,Thyroid imaging w/blood flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78015,Thyroid met imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78016,Thyroid met imaging/studies,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78018,Thyroid met imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78020,Thyroid met uptake,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78070,Parathyroid planar imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78071,Parathyrd planar w/wo subtrj,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78072,Parathyrd planar w/spect&ct,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78075,Adrenal cortex & medulla img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78099,Endocrine nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78102,Bone marrow imaging ltd,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78103,Bone marrow imaging mult,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78104,Bone marrow imaging body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78110,Plasma volume single,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78111,Plasma volume multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78120,Red cell mass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78121,Red cell mass multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78122,Blood volume,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78130,Red cell survival study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78135,Red cell survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78140,Red cell sequestration,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78185,Spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78190,Platelet survival kinetics,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78191,Platelet survival,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78195,Lymph system imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78199,Blood/lymph nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78201,Liver imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78202,Liver imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78205,Liver imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78206,Liver image (3d) with flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78215,Liver and spleen imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78216,Liver & spleen image/flow,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78226,Hepatobiliary system imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78227,Hepatobil syst image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78230,Salivary gland imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78231,Serial salivary imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78232,Salivary gland function exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78258,Esophageal motility study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78261,Gastric mucosa imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78262,Gastroesophageal reflux exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78264,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78265,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78266,Gastric emptying imag study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78267,Breath tst attain/anal c-14,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78270,Vit b-12 absorption exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78271,Vit b-12 absrp exam int fac,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78272,Vit b-12 absorp combined,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78278,Acute gi blood loss imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78282,Gi protein loss exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78290,Meckels divert exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78291,Leveen/shunt patency exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78299,Gi nuclear procedure,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78300,Bone imaging limited area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78305,Bone imaging multiple areas,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78306,Bone imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78315,Bone imaging 3 phase,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78320,Bone imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78350,Bone mineral single photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78351,Bone mineral dual photon,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78399,Musculoskeletal nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78414,Non-imaging heart function,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78428,Cardiac shunt imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78429,Myocrd img pet 1 std w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78430,Myocrd img pet rst/strs w/ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78431,Myocrd img pet rst&strs ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78432,Myocrd img pet 2rtracer,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78433,Myocrd img pet 2rtracer ct,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78434,Aqmbf pet rest & rx stress,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78445,Vascular flow imaging,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78451,Ht muscle image spect sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78452,Ht muscle image spect mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78453,Ht muscle image planar sing,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78454,Ht musc image planar mult,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78456,Acute venous thrombus image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78457,Venous thrombosis imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78458,Ven thrombosis images bilat,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78459,Myocrd img pet single study,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78466,Heart infarct image,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78468,Heart infarct image (ef),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78469,Heart infarct image (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78472,Gated heart planar single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78473,Gated heart multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78481,Heart first pass single,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78483,Heart first pass multiple,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78491,Myocrd img pet 1std rst/strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78492,Myocrd img pet mlt rst&strs,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78494,Heart image spect,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78496,Heart first pass add-on,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78499,Cardiovascular nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78579,Lung ventilation imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78580,Lung perfusion imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78582,Lung ventilat&perfus imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78597,Lung perfusion differential,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78598,Lung perf&ventilat diferentl,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78599,Respiratory nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78600,Brain image < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78601,Brain image w/flow < 4 views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78605,Brain image 4+ views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78606,Brain image w/flow 4 + views,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78607,Brain imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78608,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78609,Brain imaging (pet),Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78610,Brain flow imaging only,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78630,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78635,Csf ventriculography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78645,Csf shunt evaluation,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78647,Cerebrospinal fluid scan,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78650,Csf leakage imaging,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78660,Nuclear exam of tear flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78699,Nervous system nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78700,Kidney imaging morphol,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78701,Kidney imaging with flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78707,K flow/funct image w/o drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78708,K flow/funct image w/drug,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78709,K flow/funct image multiple,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78710,Kidney imaging (3d),Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78725,Kidney function study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78730,Urinary bladder retention,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78740,Ureteral reflux study,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78761,Testicular imaging w/flow,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78799,Genitourinary nuclear exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78800,Rp loclzj tum 1 area 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78801,Rp loclzj tum 2+area 1+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78802,Rp loclzj tum whbdy 1 d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78803,Rp loclzj tum spect 1 area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78804,Rp loclzj tum whbdy 2+d img,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78805,Abscess imaging ltd area,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78806,Abscess imaging whole body,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78807,Nuclear localization/abscess,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78811,Pet image ltd area,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78812,Pet image skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78813,Pet image full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78814,Pet image w/ct lmtd,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78815,Pet image w/ct skull-thigh,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78816,Pet image w/ct full body,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78830,Rp loclzj tum spect w/ct 1,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78831,Rp loclzj tum spect 2 areas,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78832,Rp loclzj tum spect w/ct 2,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78835,Rp quan meas single area,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,78999,Nuclear diagnostic exam,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,79005,Nuclear rx oral admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,79101,Nuclear rx iv admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,79200,Nuclear rx intracav admin,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,79300,Nuclr rx interstit colloid,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,79403,Hematopoietic nuclear tx,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,79440,Nuclear rx intra-articular,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,79445,Nuclear rx intra-arterial,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,79999,Nuclear medicine therapy,Therapeutic Radiology,Per Unit,$174.28 ,OP,$174.28 ,$174.28 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80047,Metabolic panel ionized ca,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80048,Metabolic panel total ca,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80050,General health panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80051,Electrolyte panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80053,Comprehen metabolic panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80055,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80061,Lipid panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80069,Renal function panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80074,Acute hepatitis panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80076,Hepatic function panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80081,Obstetric panel,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80143,Drug assay acetaminophen,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80145,Drug assay adalimumab,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80150,Assay of amikacin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80151,Drug assay amiodarone,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80155,Drug assay caffeine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80156,Assay carbamazepine total,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80157,Assay carbamazepine free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80158,Drug assay cyclosporine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80159,Drug assay clozapine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80161,"Asy carbamazepin 10,11-epxid",Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80162,Assay of digoxin total,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80163,Assay of digoxin free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80164,Assay dipropylacetic acd tot,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80165,Dipropylacetic acid free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80167,Drug assay felbamate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80168,Assay of ethosuximide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80169,Drug assay everolimus,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80170,Assay of gentamicin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80171,Drug screen quant gabapentin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80173,Assay of haloperidol,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80175,Drug screen quan lamotrigine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80176,Assay of lidocaine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80177,Drug scrn quan levetiracetam,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80178,Assay of lithium,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80179,Drug assay salicylate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80180,Drug scrn quan mycophenolate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80181,Drug assay flecainide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80183,Drug scrn quant oxcarbazepin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80184,Assay of phenobarbital,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80185,Assay of phenytoin total,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80186,Assay of phenytoin free,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80187,Drug assay posaconazole,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80188,Assay of primidone,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80189,Drug assay itraconzaole,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80190,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80192,Assay of procainamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80193,Drug assay leflunomide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80194,Assay of quinidine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80195,Assay of sirolimus,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80197,Assay of tacrolimus,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80198,Assay of theophylline,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80199,Drug screen quant tiagabine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80200,Assay of tobramycin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80201,Assay of topiramate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80202,Assay of vancomycin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80203,Drug screen quant zonisamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80204,Drug assay methotrexate,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80210,Drug assay rufinamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80230,Drug assay infliximab,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80235,Drug assay lacosamide,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80280,Drug assay vedolizumab,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80285,Drug assay voriconazole,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80299,Quantitative assay drug,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80300,Drug screen non tlc devices,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80301,Drug screen class list a,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80302,Drug screen prsmptv 1 class,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80303,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80304,Drug screen one/mult class,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80305,Drug test prsmv dir opt obs,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80306,Drug test prsmv instrmnt,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80307,Drug test prsmv chem anlyzr,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80320,Drug screen quantalcohols,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80321,Alcohols biomarkers 1or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80322,Alcohols biomarkers 3/more,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80323,Alkaloids nos,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80324,Drug screen amphetamines 1/2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80325,Amphetamines 3or 4,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80326,Amphetamines 5 or more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80327,Anabolic steroid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80328,Anabolic steroid 3 or more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80329,Analgesics non-opioid 1 or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80330,Analgesics non-opioid 3-5,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80331,Analgesics non-opioid 6/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80332,Antidepressants class 1 or 2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80333,Antidepressants class 3-5,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80334,Antidepressants class 6/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80335,Antidepressant tricyclic 1/2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80336,Antidepressant tricyclic 3-5,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80337,Tricyclic & cyclicals 6/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80338,Antidepressant not specified,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80339,Antiepileptics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80340,Antiepileptics nos 4-6,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80341,Antiepileptics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80342,Antipsychotics nos 1-3,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80343,Antipsychotics nos 4-6,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80344,Antipsychotics nos 7/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80345,Drug screening barbiturates,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80346,Benzodiazepines1-12,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80347,Benzodiazepines 13 or more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80348,Drug screening buprenorphine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80349,Cannabinoids natural,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80350,Cannabinoids synthetic 1-3,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80351,Cannabinoids synthetic 4-6,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80352,Cannabinoid synthetic 7/more,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80353,Drug screening cocaine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80354,Drug screening fentanyl,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80355,Gabapentin non-blood,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80356,Heroin metabolite,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80357,Ketamine and norketamine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80358,Drug screening methadone,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80359,Methylenedioxyamphetamines,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80360,Methylphenidate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80361,Opiates 1 or more,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80362,Opioids & opiate analogs 1/2,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80363,Opioids & opiate analogs 3/4,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80364,Opioid &opiate analog 5/more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80365,Drug screening oxycodone,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80366,Drug screening pregabalin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80367,Drug screening propoxyphene,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80368,Sedative hypnotics,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80369,Skeletal muscle relaxant 1/2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80370,Skel musc relaxant 3 or more,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80371,Stimulants synthetic,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80372,Drug screening tapentadol,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80373,Drug screening tramadol,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80374,Stereoisomer analysis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80375,Drug/substance nos 1-3,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80376,Drug/substance nos 4-6,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80377,Drug/substance nos 7/more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80400,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80402,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80406,Acth stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80408,Aldosterone suppression eval,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80410,Calcitonin stimul panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80412,Crh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80414,Testosterone response panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80415,Tot estradiol response panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80416,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80417,Renin stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80418,Pituitary evaluation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80420,Dexamethasone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80422,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80424,Glucagon tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80426,Gonadotropin hormone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80428,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80430,Growth hormone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80432,Insulin suppression panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80434,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80435,Insulin tolerance panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80436,Metyrapone panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80438,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80439,Trh stimulation panel,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80500,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,80502,Lab pathology consultation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81000,Urinalysis nonauto w/scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81001,Urinalysis auto w/scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81002,Urinalysis nonauto w/o scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81003,Urinalysis auto w/o scope,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81005,Urinalysis,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81007,Urine screen for bacteria,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81015,Microscopic exam of urine,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81020,Urinalysis glass test,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81025,Urine pregnancy test,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81050,Urinalysis volume measure,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81099,Urinalysis test procedure,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81105,Hpa-1 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81106,Hpa-2 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81107,Hpa-3 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81108,Hpa-4 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81109,Hpa-5 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81110,Hpa-6 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81111,Hpa-9 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81112,Hpa-15 genotyping,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81120,Idh1 common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81121,Idh2 common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81161,Dmd dup/delet analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81162,Brca1&2 gen full seq dup/del,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81163,Brca1&2 gene full seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81164,Brca1&2 gen ful dup/del alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81165,Brca1 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81166,Brca1 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81167,Brca2 gene full dup/del alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81168,Ccnd1/igh translocation alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81170,Abl1 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81171,Aff2 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81172,Aff2 gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81173,Ar gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81174,Ar gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81175,Asxl1 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81176,Asxl1 gene target seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81177,Atn1 gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81178,Atxn1 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81179,Atxn2 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81180,Atxn3 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81181,Atxn7 gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81182,Atxn8os gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81183,Atxn10 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81184,Cacna1a gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81185,Cacna1a gene full gene seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81186,Cacna1a gen known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81187,Cnbp gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81188,Cstb gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81189,Cstb gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81190,Cstb gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81191,Ntrk1 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81192,Ntrk2 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81193,Ntrk3 translocation analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81194,Ntrk translocation analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81200,Aspa gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81201,Apc gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81202,Apc gene known fam variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81203,Apc gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81204,Ar gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81205,Bckdhb gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81206,Bcr/abl1 gene major bp,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81207,Bcr/abl1 gene minor bp,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81208,Bcr/abl1 gene other bp,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81209,Blm gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81210,Braf gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81211,Brca1&2 seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81212,Brca1&2 185&5385&6174 vrnt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81213,Brca1&2 uncom dup/del var,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81214,Brca1 full seq & com dup/del,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81215,Brca1 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81216,Brca2 gene full seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81217,Brca2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81218,Cebpa gene full sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81219,Calr gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81220,Cftr gene com variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81221,Cftr gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81222,Cftr gene dup/delet variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81223,Cftr gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81224,Cftr gene intron poly t,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81225,Cyp2c19 gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81226,Cyp2d6 gene com variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81227,Cyp2c9 gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81228,Cytogen micrarray copy nmbr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81229,Cytogen m array copy no&snp,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81230,Cyp3a4 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81231,Cyp3a5 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81232,Dpyd gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81233,Btk gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81234,Dmpk gene detc abnor allele,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81235,Egfr gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81236,Ezh2 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81237,Ezh2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81238,F9 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81239,Dmpk gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81240,F2 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81241,F5 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81242,Fancc gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81243,Fmr1 gene detection,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81244,Fmr1 gene charac alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81245,Flt3 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81246,Flt3 gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81247,G6pd gene alys cmn variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81248,G6pd known familial variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81249,G6pd full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81250,G6pc gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81251,Gba gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81252,Gjb2 gene full sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81253,Gjb2 gene known fam variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81254,Gjb6 gene com variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81255,Hexa gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81256,Hfe gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81257,Hba1/hba2 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81258,Hba1/hba2 gene fam vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81259,Hba1/hba2 full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81260,Ikbkap gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81261,Igh gene rearrange amp meth,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81262,Igh gene rearrang dir probe,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81263,Igh vari regional mutation,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81264,Igk rearrangeabn clonal pop,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81265,Str markers specimen anal,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81266,Str markers spec anal addl,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81267,Chimerism anal no cell selec,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81268,Chimerism anal w/cell select,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81269,Hba1/hba2 gene dup/del vrnts,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81270,Jak2 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81271,Htt gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81272,Kit gene targeted seq analys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81273,Kit gene analys d816 variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81274,Htt gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81275,Kras gene variants exon 2,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81276,Kras gene addl variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81277,Cytogenomic neo microra alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81278,Igh/bcl2 translocation alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81279,Jak2 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81280,Long qt synd gene full seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81281,Long qt synd known fam var,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81282,Long qt syn gene dup/dlt var,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81283,Ifnl3 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81284,Fxn gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81285,Fxn gene charac alleles,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81286,Fxn gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81287,Mgmt gene prmtr mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81288,Mlh1 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81289,Fxn gene known famil variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81290,Mcoln1 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81291,Mthfr gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81292,Mlh1 gene full seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81293,Mlh1 gene known variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81294,Mlh1 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81295,Msh2 gene full seq,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81296,Msh2 gene known variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81297,Msh2 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81298,Msh6 gene full seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81299,Msh6 gene known variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81300,Msh6 gene dup/delete variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81301,Microsatellite instability,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81302,Mecp2 gene full seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81303,Mecp2 gene known variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81304,Mecp2 gene dup/delet variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81305,Myd88 gene p.leu265pro vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81306,Nudt15 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81307,Palb2 gene full gene seq,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81308,Palb2 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81309,Pik3ca gene trgt seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81310,Npm1 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81311,Nras gene variants exon 2&3,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81312,Pabpn1 gene detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81313,Pca3/klk3 antigen,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81314,Pdgfra gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81315,Pml/raralpha com breakpoints,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81316,Pml/raralpha 1 breakpoint,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81317,Pms2 gene full seq analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81318,Pms2 known familial variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81319,Pms2 gene dup/delet variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81320,Plcg2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81321,Pten gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81322,Pten gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81323,Pten gene dup/delet variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81324,Pmp22 gene dup/delet,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81325,Pmp22 gene full sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81326,Pmp22 gene known fam variant,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81327,Sept9 gen prmtr mthyltn alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81328,Slco1b1 gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81329,Smn1 gene dos/deletion alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81330,Smpd1 gene common variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81331,Snrpn/ube3a gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81332,Serpina1 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81333,Tgfbi gene common variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81334,Runx1 gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81335,Tpmt gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81336,Smn1 gene full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81337,Smn1 gen nown famil seq vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81338,Mpl gene common variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81339,Mpl gene seq alys exon 10,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81340,Trb@ gene rearrange amplify,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81341,Trb@ gene rearrange dirprobe,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81342,Trg gene rearrangement anal,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81343,Ppp2r2b gen detc abnor allel,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81344,Tbp gene detc abnor alleles,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81345,Tert gene targeted seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81346,Tyms gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81347,Sf3b1 gene common variants,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81348,Srsf2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81350,Ugt1a1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81351,Tp53 gene full gene sequence,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81352,Tp53 gene trgt sequence alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81353,Tp53 gene known famil vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81355,Vkorc1 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81357,U2af1 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81360,Zrsr2 gene common variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81361,Hbb gene com variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81362,Hbb gene known fam variant,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81363,Hbb gene dup/del variants,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81364,Hbb full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81370,Hla i & ii typing lr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81371,Hla i & ii type verify lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81372,Hla i typing complete lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81373,Hla i typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81374,Hla i typing 1 antigen lr,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81375,Hla ii typing ag equiv lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81376,Hla ii typing 1 locus lr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81377,Hla ii type 1 ag equiv lr,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81378,Hla i & ii typing hr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81379,Hla i typing complete hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81380,Hla i typing 1 locus hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81381,Hla i typing 1 allele hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81382,Hla ii typing 1 loc hr,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81383,Hla ii typing 1 allele hr,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81400,Mopath procedure level 1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81401,Mopath procedure level 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81402,Mopath procedure level 3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81403,Mopath procedure level 4,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81404,Mopath procedure level 5,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81405,Mopath procedure level 6,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81406,Mopath procedure level 7,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81407,Mopath procedure level 8,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81408,Mopath procedure level 9,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81410,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81411,Aortic dysfunction/dilation,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81412,Ashkenazi jewish assoc dis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81413,Car ion chnnlpath inc 10 gns,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81414,Car ion chnnlpath inc 2 gns,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81415,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81416,Exome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81417,Exome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81419,Epilepsy gen seq alys panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81420,Fetal chrmoml aneuploidy,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81422,Fetal chrmoml microdeltj,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81425,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81426,Genome sequence analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81427,Genome re-evaluation,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81430,Hearing loss sequence analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81431,Hearing loss dup/del analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81434,Hereditary retinal disorders,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81435,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81436,Hereditary colon ca dsordrs,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81437,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81438,Heredtry nurondcrn tum dsrdr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81439,Hrdtry cardmypy gene panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81440,Mitochondrial gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81442,Noonan spectrum disorders,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81443,Genetic tstg severe inh cond,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81445,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81448,Hrdtry perph neurphy panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81450,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81455,Targeted genomic seq analys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81460,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81465,Whole mitochondrial genome,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81470,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81471,X-linked intellectual dblt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81479,Unlisted molecular pathology,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81490,Autoimmune rheumatoid arthr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81493,Cor artery disease mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81500,Onco (ovar) two proteins,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81503,Onco (ovar) five proteins,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81504,Oncology tissue of origin,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81506,Endo assay seven anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81507,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81508,Ftl cgen abnor two proteins,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81509,Ftl cgen abnor 3 proteins,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81510,Ftl cgen abnor three anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81511,Ftl cgen abnor four anal,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81512,Ftl cgen abnor five anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81513,Nfct ds bv rna vag flu alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81514,Nfct ds bv&vaginitis dna alg,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81518,Onc brst mrna 11 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81519,Oncology breast mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81520,Onc breast mrna 58 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81521,Onc breast mrna 70 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81522,Onc breast mrna 12 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81525,Oncology colon mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81528,Oncology colorectal scr,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81529,Onc cutan mlnma mrna 31 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81535,Oncology gynecologic,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81536,Oncology gynecologic,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81538,Oncology lung,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81539,Oncology prostate prob score,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81540,Oncology tum unknown origin,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81541,Onc prostate mrna 46 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81542,Onc prostate mrna 22 cnt gen,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81545,Oncology thyroid,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81546,"Onc thyr mrna 10,196 gen alg",Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81551,Onc prostate 3 genes,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81552,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81554,Pulm ds ipf mrna 190 gen alg,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81595,Cardiology hrt trnspl mrna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81596,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,81599,Unlisted maaa,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82009,Test for acetone/ketones,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82010,Acetone assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82013,Acetylcholinesterase assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82016,Acylcarnitines qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82017,Acylcarnitines quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82024,Assay of acth,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82030,Assay of adp & amp,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82040,Assay of serum albumin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82042,Other source albumin quan ea,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82043,Ur albumin quantitative,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82044,Ur albumin semiquantitative,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82045,Albumin ischemia modified,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82075,Assay of breath ethanol,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82077,Assay spec xcp ur&breath ia,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82085,Assay of aldolase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82088,Assay of aldosterone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82103,Alpha-1-antitrypsin total,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82104,Alpha-1-antitrypsin pheno,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82105,Alpha-fetoprotein serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82106,Alpha-fetoprotein amniotic,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82107,Alpha-fetoprotein l3,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82108,Assay of aluminum,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82120,Amines vaginal fluid qual,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82127,Amino acid single qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82128,Amino acids mult qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82131,Amino acids single quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82135,Assay aminolevulinic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82136,Amino acids quant 2-5,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82139,Amino acids quan 6 or more,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82140,Assay of ammonia,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82143,Amniotic fluid scan,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82150,Assay of amylase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82154,Androstanediol glucuronide,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82157,Assay of androstenedione,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82160,Assay of androsterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82163,Assay of angiotensin ii,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82164,Angiotensin i enzyme test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82172,Assay of apolipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82175,Assay of arsenic,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82180,Assay of ascorbic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82190,Atomic absorption,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82232,Assay of beta-2 protein,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82239,Bile acids total,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82240,Bile acids cholylglycine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82247,Bilirubin total,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82248,Bilirubin direct,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82252,Fecal bilirubin test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82261,Assay of biotinidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82270,Occult blood feces,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82271,Occult blood other sources,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82272,Occult bld feces 1-3 tests,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82274,Assay test for blood fecal,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82286,Assay of bradykinin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82300,Assay of cadmium,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82306,Vitamin d 25 hydroxy,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82308,Assay of calcitonin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82310,Assay of calcium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82330,Assay of calcium,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82331,Calcium infusion test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82340,Assay of calcium in urine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82355,Calculus analysis qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82360,Calculus assay quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82365,Calculus spectroscopy,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82370,X-ray assay calculus,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82373,Assay c-d transfer measure,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82374,Assay blood carbon dioxide,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82375,Assay carboxyhb quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82376,Assay carboxyhb qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82378,Carcinoembryonic antigen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82379,Assay of carnitine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82380,Assay of carotene,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82382,Assay urine catecholamines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82383,Assay blood catecholamines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82384,Assay three catecholamines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82387,Assay of cathepsin-d,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82390,Assay of ceruloplasmin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82397,Chemiluminescent assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82415,Assay of chloramphenicol,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82435,Assay of blood chloride,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82436,Assay of urine chloride,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82438,Assay other fluid chlorides,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82441,Test for chlorohydrocarbons,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82465,Assay bld/serum cholesterol,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82480,Assay serum cholinesterase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82482,Assay rbc cholinesterase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82485,Assay chondroitin sulfate,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82486,Gas/liquid chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82487,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82488,Paper chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82489,Thin layer chromatography,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82491,Chromotography quant sing,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82492,Chromotography quant mult,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82495,Assay of chromium,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82507,Assay of citrate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82523,Collagen crosslinks,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82525,Assay of copper,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82528,Assay of corticosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82530,Cortisol free,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82533,Total cortisol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82540,Assay of creatine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82541,Column chromotography qual,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82542,Col chromotography qual/quan,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82543,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82544,Column chromotograph/isotope,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82550,Assay of ck (cpk),Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82552,Assay of cpk in blood,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82553,Creatine mb fraction,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82554,Creatine isoforms,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82565,Assay of creatinine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82570,Assay of urine creatinine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82575,Creatinine clearance test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82585,Assay of cryofibrinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82595,Assay of cryoglobulin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82600,Assay of cyanide,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82607,Vitamin b-12,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82608,B-12 binding capacity,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82610,Cystatin c,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82615,Test for urine cystines,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82626,Dehydroepiandrosterone,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82627,Dehydroepiandrosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82633,Desoxycorticosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82634,Deoxycortisol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82638,Assay of dibucaine number,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82642,Dihydrotestosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82652,Vit d 1 25-dihydroxy,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82656,Pancreatic elastase fecal,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82657,Enzyme cell activity,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82658,Enzyme cell activity ra,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82664,Electrophoretic test,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82668,Assay of erythropoietin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82670,Assay of total estradiol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82671,Assay of estrogens,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82672,Assay of estrogen,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82677,Assay of estriol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82679,Assay of estrone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82681,Assay dir meas fr estradiol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82693,Assay of ethylene glycol,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82696,Assay of etiocholanolone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82705,Fats/lipids feces qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82710,Fats/lipids feces quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82715,Assay of fecal fat,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82725,Assay of blood fatty acids,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82726,Long chain fatty acids,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82728,Assay of ferritin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82731,Assay of fetal fibronectin,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82735,Assay of fluoride,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82746,Assay of folic acid serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82747,Assay of folic acid rbc,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82757,Assay of semen fructose,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82759,Assay of rbc galactokinase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82760,Assay of galactose,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82775,Assay galactose transferase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82776,Galactose transferase test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82777,Galectin-3,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82784,Assay iga/igd/igg/igm each,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82785,Assay of ige,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82787,Igg 1 2 3 or 4 each,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82800,Blood ph,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82803,Blood gases any combination,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82805,Blood gases w/o2 saturation,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82810,Blood gases o2 sat only,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82820,Hemoglobin-oxygen affinity,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82930,Gastric analy w/ph ea spec,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82938,Gastrin test,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82941,Assay of gastrin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82943,Assay of glucagon,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82945,Glucose other fluid,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82946,Glucagon tolerance test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82947,Assay glucose blood quant,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82948,Reagent strip/blood glucose,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82950,Glucose test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82951,Glucose tolerance test (gtt),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82952,Gtt-added samples,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82955,Assay of g6pd enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82960,Test for g6pd enzyme,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82962,Glucose blood test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82963,Assay of glucosidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82965,Assay of gdh enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82977,Assay of ggt,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82978,Assay of glutathione,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82979,Assay rbc glutathione,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,82985,Assay of glycated protein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83001,Assay of gonadotropin (fsh),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83002,Assay of gonadotropin (lh),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83003,Assay growth hormone (hgh),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83006,Growth stimulation gene 2,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83009,H pylori (c-13) blood,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83010,Assay of haptoglobin quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83012,Assay of haptoglobins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83013,H pylori (c-13) breath,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83014,H pylori drug admin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83015,Heavy metal qual any anal,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83018,Heavy metal quant each nes,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83020,Hemoglobin electrophoresis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83021,Hemoglobin chromotography,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83026,Hemoglobin copper sulfate,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83030,Fetal hemoglobin chemical,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83033,Fetal hemoglobin assay qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83036,Glycosylated hemoglobin test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83037,Glycosylated hb home device,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83045,Blood methemoglobin test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83050,Blood methemoglobin assay,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83051,Assay of plasma hemoglobin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83060,Blood sulfhemoglobin assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83065,Assay of hemoglobin heat,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83068,Hemoglobin stability screen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83069,Assay of urine hemoglobin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83070,Assay of hemosiderin qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83080,Assay of b hexosaminidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83088,Assay of histamine,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83090,Assay of homocystine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83150,Assay of homovanillic acid,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83491,Assay of corticosteroids 17,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83497,Assay of 5-hiaa,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83498,Assay of progesterone 17-d,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83499,Assay of progesterone 20-,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83500,Assay free hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83505,Assay total hydroxyproline,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83516,Immunoassay nonantibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83518,Immunoassay dipstick,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83519,Ria nonantibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83520,Immunoassay quant nos nonab,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83525,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83527,Assay of insulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83528,Assay of intrinsic factor,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83540,Assay of iron,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83550,Iron binding test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83570,Assay of idh enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83582,Assay of ketogenic steroids,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83586,Assay 17- ketosteroids,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83593,Fractionation ketosteroids,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83605,Assay of lactic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83615,Lactate (ld) (ldh) enzyme,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83625,Assay of ldh enzymes,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83630,Lactoferrin fecal (qual),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83631,Lactoferrin fecal (quant),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83632,Placental lactogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83633,Test urine for lactose,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83655,Assay of lead,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83661,L/s ratio fetal lung,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83662,Foam stability fetal lung,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83663,Fluoro polarize fetal lung,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83664,Lamellar bdy fetal lung,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83670,Assay of lap enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83690,Assay of lipase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83695,Assay of lipoprotein(a),Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83698,Assay lipoprotein pla2,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83700,Lipopro bld electrophoretic,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83701,Lipoprotein bld hr fraction,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83704,Lipoprotein bld quan part,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83718,Assay of lipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83719,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83721,Assay of blood lipoprotein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83722,Lipoprtn dir meas sd ldl chl,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83727,Assay of lrh hormone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83735,Assay of magnesium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83775,Assay malate dehydrogenase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83785,Assay of manganese,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83788,Mass spectrometry qual,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83789,Mass spectrometry qual/quan,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83825,Assay of mercury,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83835,Assay of metanephrines,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83857,Assay of methemalbumin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83861,Microfluid analy tears,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83864,Mucopolysaccharides,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83872,Assay synovial fluid mucin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83873,Assay of csf protein,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83874,Assay of myoglobin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83876,Assay myeloperoxidase,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83880,Assay of natriuretic peptide,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83883,Assay nephelometry not spec,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83885,Assay of nickel,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83915,Assay of nucleotidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83916,Oligoclonal bands,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83918,Organic acids total quant,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83919,Organic acids qual each,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83921,Organic acid single quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83930,Assay of blood osmolality,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83935,Assay of urine osmolality,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83937,Assay of osteocalcin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83945,Assay of oxalate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83950,Oncoprotein her-2/neu,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83951,Oncoprotein dcp,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83970,Assay of parathormone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83986,Assay ph body fluid nos,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83987,Exhaled breath condensate,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83992,Assay for phencyclidine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,83993,Assay for calprotectin fecal,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84030,Assay of blood pku,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84035,Assay of phenylketones,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84060,Assay acid phosphatase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84061,Phosphatase forensic exam,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84066,Assay prostate phosphatase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84075,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84078,Assay alkaline phosphatase,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84080,Assay alkaline phosphatases,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84081,Assay phosphatidylglycerol,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84085,Assay of rbc pg6d enzyme,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84087,Assay phosphohexose enzymes,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84100,Assay of phosphorus,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84105,Assay of urine phosphorus,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84106,Test for porphobilinogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84110,Assay of porphobilinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84112,Eval amniotic fluid protein,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84119,Test urine for porphyrins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84120,Assay of urine porphyrins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84126,Assay of feces porphyrins,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84132,Assay of serum potassium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84133,Assay of urine potassium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84134,Assay of prealbumin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84135,Assay of pregnanediol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84138,Assay of pregnanetriol,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84140,Assay of pregnenolone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84143,Assay of 17-hydroxypregneno,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84144,Assay of progesterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84145,Procalcitonin (pct),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84146,Assay of prolactin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84150,Assay of prostaglandin,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84152,Assay of psa complexed,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84153,Assay of psa total,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84154,Assay of psa free,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84155,Assay of protein serum,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84156,Assay of protein urine,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84157,Assay of protein other,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84160,Assay of protein any source,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84163,Pappa serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84165,Protein e-phoresis serum,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84166,Protein e-phoresis/urine/csf,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84181,Western blot test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84182,Protein western blot test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84202,Assay rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84203,Test rbc protoporphyrin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84206,Assay of proinsulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84207,Assay of vitamin b-6,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84210,Assay of pyruvate,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84220,Assay of pyruvate kinase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84228,Assay of quinine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84233,Assay of estrogen,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84234,Assay of progesterone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84235,Assay of endocrine hormone,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84238,Assay nonendocrine receptor,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84244,Assay of renin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84252,Assay of vitamin b-2,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84255,Assay of selenium,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84260,Assay of serotonin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84270,Assay of sex hormone globul,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84275,Assay of sialic acid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84285,Assay of silica,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84295,Assay of serum sodium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84300,Assay of urine sodium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84302,Assay of sweat sodium,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84305,Assay of somatomedin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84307,Assay of somatostatin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84311,Spectrophotometry,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84315,Body fluid specific gravity,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84375,Chromatogram assay sugars,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84376,Sugars single qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84377,Sugars multiple qual,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84378,Sugars single quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84379,Sugars multiple quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84392,Assay of urine sulfate,Laboratory,Per Unit,$2.29 ,OP,$2.29 ,$2.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84402,Assay of free testosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84403,Assay of total testosterone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84410,Testosterone bioavailable,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84425,Assay of vitamin b-1,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84430,Assay of thiocyanate,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84431,Thromboxane urine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84432,Assay of thyroglobulin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84436,Assay of total thyroxine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84437,Assay of neonatal thyroxine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84439,Assay of free thyroxine,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84442,Assay of thyroid activity,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84443,Assay thyroid stim hormone,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84445,Assay of tsi globulin,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84446,Assay of vitamin e,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84449,Assay of transcortin,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84450,Transferase (ast) (sgot),Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84460,Alanine amino (alt) (sgpt),Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84466,Assay of transferrin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84478,Assay of triglycerides,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84479,Assay of thyroid (t3 or t4),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84480,Assay triiodothyronine (t3),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84481,Free assay (ft-3),Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84482,T3 reverse,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84484,Assay of troponin quant,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84485,Assay duodenal fluid trypsin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84488,Test feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84490,Assay of feces for trypsin,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84510,Assay of tyrosine,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84512,Assay of troponin qual,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84520,Assay of urea nitrogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84525,Urea nitrogen semi-quant,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84540,Assay of urine/urea-n,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84545,Urea-n clearance test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84550,Assay of blood/uric acid,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84560,Assay of urine/uric acid,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84577,Assay of feces/urobilinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84578,Test urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84580,Assay of urine urobilinogen,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84583,Assay of urine urobilinogen,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84585,Assay of urine vma,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84586,Assay of vip,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84588,Assay of vasopressin,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84590,Assay of vitamin a,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84591,Assay of nos vitamin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84597,Assay of vitamin k,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84600,Assay of volatiles,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84620,Xylose tolerance test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84630,Assay of zinc,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84681,Assay of c-peptide,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84702,Chorionic gonadotropin test,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84703,Chorionic gonadotropin assay,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84704,Hcg free betachain test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84830,Ovulation tests,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,84999,Clinical chemistry test,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85002,Bleeding time test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85004,Automated diff wbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85007,Bl smear w/diff wbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85008,Bl smear w/o diff wbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85009,Manual diff wbc count b-coat,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85013,Spun microhematocrit,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85014,Hematocrit,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85018,Hemoglobin,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85025,Complete cbc w/auto diff wbc,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85027,Complete cbc automated,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85032,Manual cell count each,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85041,Automated rbc count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85044,Manual reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85045,Automated reticulocyte count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85046,Reticyte/hgb concentrate,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85048,Automated leukocyte count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85049,Automated platelet count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85055,Reticulated platelet assay,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85060,Blood smear interpretation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85097,Bone marrow interpretation,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85130,Chromogenic substrate assay,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85170,Blood clot retraction,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85175,Blood clot lysis time,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85210,Clot factor ii prothrom spec,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85220,Blooc clot factor v test,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85230,Clot factor vii proconvertin,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85240,Clot factor viii ahg 1 stage,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85244,Clot factor viii reltd antgn,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85245,Clot factor viii vw ristoctn,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85246,Clot factor viii vw antigen,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85247,Clot factor viii multimetric,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85250,Clot factor ix ptc/chrstmas,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85260,Clot factor x stuart-power,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85270,Clot factor xi pta,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85280,Clot factor xii hageman,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85290,Clot factor xiii fibrin stab,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85291,Clot factor xiii fibrin scrn,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85292,Clot factor fletcher fact,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85293,Clot factor wght kininogen,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85300,Antithrombin iii activity,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85301,Antithrombin iii antigen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85302,Clot inhibit prot c antigen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85303,Clot inhibit prot c activity,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85305,Clot inhibit prot s total,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85306,Clot inhibit prot s free,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85307,Assay activated protein c,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85335,Factor inhibitor test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85337,Thrombomodulin,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85345,Coagulation time lee & white,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85347,Coagulation time activated,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85348,Coagulation time otr method,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85360,Euglobulin lysis,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85362,Fibrin degradation products,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85366,Fibrinogen test,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85370,Fibrinogen test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85378,Fibrin degrade semiquant,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85379,Fibrin degradation quant,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85380,Fibrin degradj d-dimer,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85384,Fibrinogen activity,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85385,Fibrinogen antigen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85390,Fibrinolysins screen i&r,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85396,Clotting assay whole blood,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85397,Clotting funct activity,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85400,Fibrinolytic plasmin,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85410,Fibrinolytic antiplasmin,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85415,Fibrinolytic plasminogen,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85420,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85421,Fibrinolytic plasminogen,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85441,Heinz bodies direct,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85445,Heinz bodies induced,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85460,Hemoglobin fetal,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85461,Hemoglobin fetal,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85475,Hemolysin acid,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85520,Heparin assay,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85525,Heparin neutralization,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85530,Heparin-protamine tolerance,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85536,Iron stain peripheral blood,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85540,Wbc alkaline phosphatase,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85547,Rbc mechanical fragility,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85549,Muramidase,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85555,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85557,Rbc osmotic fragility,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85576,Blood platelet aggregation,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85597,Phospholipid pltlt neutraliz,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85598,Hexagnal phosph pltlt neutrl,Laboratory,Per Unit,$6.92 ,OP,$6.92 ,$6.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85610,Prothrombin time,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85611,Prothrombin test,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85612,Viper venom prothrombin time,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85613,Russell viper venom diluted,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85635,Reptilase test,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85651,Rbc sed rate nonautomated,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85652,Rbc sed rate automated,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85660,Rbc sickle cell test,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85670,Thrombin time plasma,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85675,Thrombin time titer,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85705,Thromboplastin inhibition,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85730,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85732,Thromboplastin time partial,Laboratory,Per Unit,$2.33 ,OP,$2.33 ,$2.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85810,Blood viscosity examination,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,85999,Hematology procedure,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86000,Agglutinins febrile antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86001,Allergen specific igg,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86003,Allg spec ige crude xtrc ea,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86005,Allg spec ige multiallg scr,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86008,Allg spec ige recomb ea,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86021,Wbc antibody identification,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86022,Platelet antibodies,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86023,Immunoglobulin assay,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86038,Antinuclear antibodies,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86039,Antinuclear antibodies (ana),Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86060,Antistreptolysin o titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86063,Antistreptolysin o screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86140,C-reactive protein,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86141,C-reactive protein hs,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86146,Beta-2 glycoprotein antibody,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86147,Cardiolipin antibody ea ig,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86148,Anti-phospholipid antibody,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86152,Cell enumeration & id,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86153,Cell enumeration phys interp,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86155,Chemotaxis assay,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86156,Cold agglutinin screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86157,Cold agglutinin titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86160,Complement antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86161,Complement/function activity,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86162,Complement total (ch50),Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86171,Complement fixation each,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86185,Counterimmunoelectrophoresis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86200,Ccp antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86215,Deoxyribonuclease antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86225,Dna antibody native,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86226,Dna antibody single strand,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86235,Nuclear antigen antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86243,Fc receptor,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86255,Fluorescent antibody screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86256,Fluorescent antibody titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86277,Growth hormone antibody,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86280,Hemagglutination inhibition,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86294,Immunoassay tumor qual,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86300,Immunoassay tumor ca 15-3,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86301,Immunoassay tumor ca 19-9,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86304,Immunoassay tumor ca 125,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86305,Human epididymis protein 4,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86308,Heterophile antibody screen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86309,Heterophile antibody titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86310,Heterophile antibody absrbj,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86316,Immunoassay tumor other,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86317,Immunoassay infectious agent,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86318,Ia infectious agent antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86320,Serum immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86325,Other immunoelectrophoresis,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86327,Immunoelectrophoresis assay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86328,Ia nfct ab sarscov2 covid19,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86329,Immunodiffusion nes,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86331,Immunodiffusion ouchterlony,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86332,Immune complex assay,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86334,Immunofix e-phoresis serum,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86335,Immunfix e-phorsis/urine/csf,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86336,Inhibin a,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86337,Insulin antibodies,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86340,Intrinsic factor antibody,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86341,Islet cell antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86343,Leukocyte histamine release,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86344,Leukocyte phagocytosis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86352,Cell function assay w/stim,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86353,Lymphocyte transformation,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86355,B cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86356,Mononuclear cell antigen,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86357,Nk cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86359,T cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86360,T cell absolute count/ratio,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86361,T cell absolute count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86367,Stem cells total count,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86376,Microsomal antibody each,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86378,Migration inhibitory factor,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86382,Neutralization test viral,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86384,Nitroblue tetrazolium dye,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86386,Nuclear matrix protein 22,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86403,Particle agglut antbdy scrn,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86406,Particle agglut antbdy titr,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86408,Neutrlzg antb sarscov2 scr,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86409,Neutrlzg antb sarscov2 titer,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86413,Sars-cov-2 antb quantitative,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86430,Rheumatoid factor test qual,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86431,Rheumatoid factor quant,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86480,Tb test cell immun measure,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86481,Tb ag response t-cell susp,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86485,Skin test candida,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86486,Skin test nos antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86490,Coccidioidomycosis skin test,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86510,Histoplasmosis skin test,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86580,Tb intradermal test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86590,Streptokinase antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86592,Syphilis test non-trep qual,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86593,Syphilis test non-trep quant,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86602,Antinomyces antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86603,Adenovirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86606,Aspergillus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86609,Bacterium antibody,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86611,Bartonella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86612,Blastomyces antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86615,Bordetella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86617,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86618,Lyme disease antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86619,Borrelia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86622,Brucella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86625,Campylobacter antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86628,Candida antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86631,Chlamydia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86632,Chlamydia igm antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86635,Coccidioides antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86638,Q fever antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86641,Cryptococcus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86644,Cmv antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86645,Cmv antibody igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86648,Diphtheria antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86651,Encephalitis californ antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86652,Encephaltis east eqne anbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86653,Encephaltis st louis antbody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86654,Encephaltis west eqne antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86658,Enterovirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86663,Epstein-barr antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86664,Epstein-barr nuclear antigen,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86665,Epstein-barr capsid vca,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86666,Ehrlichia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86668,Francisella tularensis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86671,Fungus nes antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86674,Giardia lamblia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86677,Helicobacter pylori antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86682,Helminth antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86684,Hemophilus influenza antibdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86687,Htlv-i antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86688,Htlv-ii antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86689,Htlv/hiv confirmj antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86692,Hepatitis delta agent antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86694,Herpes simplex nes antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86695,Herpes simplex type 1 test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86696,Herpes simplex type 2 test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86698,Histoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86701,Hiv-1antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86702,Hiv-2 antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86704,Hep b core antibody total,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86705,Hep b core antibody igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86706,Hep b surface antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86707,Hepatitis be antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86708,Hepatitis a antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86709,Hepatitis a igm antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86710,Influenza virus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86711,John cunningham antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86713,Legionella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86717,Leishmania antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86720,Leptospira antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86723,Listeria monocytogenes,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86727,Lymph choriomeningitis ab,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86729,Lympho venereum antibody,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86732,Mucormycosis antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86735,Mumps antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86738,Mycoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86741,Neisseria meningitidis,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86744,Nocardia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86747,Parvovirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86750,Malaria antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86753,Protozoa antibody nos,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86756,Respiratory virus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86757,Rickettsia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86759,Rotavirus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86762,Rubella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86765,Rubeola antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86768,Salmonella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86769,Sars-cov-2 covid-19 antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86771,Shigella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86774,Tetanus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86777,Toxoplasma antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86778,Toxoplasma antibody igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86780,Treponema pallidum,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86784,Trichinella antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86787,Varicella-zoster antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86788,West nile virus ab igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86789,West nile virus antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86790,Virus antibody nos,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86793,Yersinia antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86794,Zika virus igm antibody,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86800,Thyroglobulin antibody,Laboratory,Per Unit,$8.65 ,OP,$8.65 ,$8.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86803,Hepatitis c ab test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86804,Hep c ab test confirm,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86805,Lymphocytotoxicity assay,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86806,Lymphocytotoxicity assay,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86807,Cytotoxic antibody screening,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86808,Cytotoxic antibody screening,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86812,Hla typing a b or c,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86813,Hla typing a b or c,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86816,Hla typing dr/dq,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86817,Hla typing dr/dq,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86821,Lymphocyte culture mixed,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86822,Lymphocyte culture primed,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86825,Hla x-math non-cytotoxic,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86826,Hla x-match noncytotoxc addl,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86828,Hla class i&ii antibody qual,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86829,Hla class i/ii antibody qual,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86830,Hla class i phenotype qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86831,Hla class ii phenotype qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86832,Hla class i high defin qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86833,Hla class ii high defin qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86834,Hla class i semiquant panel,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86835,Hla class ii semiquant panel,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86849,Immunology procedure,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86850,Rbc antibody screen,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86860,Rbc antibody elution,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86870,Rbc antibody identification,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86880,Coombs test direct,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86885,Coombs test indirect qual,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86886,Coombs test indirect titer,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86900,Blood typing serologic abo,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86901,Blood typing serologic rh(d),Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86902,Blood type antigen donor ea,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86904,Blood typing patient serum,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86905,Blood typing rbc antigens,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86906,Bld typing serologic rh phnt,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86910,Blood typing paternity test,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86911,Blood typing antigen system,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86920,Compatibility test spin,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86921,Compatibility test incubate,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86922,Compatibility test antiglob,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86923,Compatibility test electric,Pathology,Per Unit,$23.23 ,OP,$23.23 ,$23.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86940,Hemolysins/agglutinins auto,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86941,Hemolysins/agglutinins,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,86999,Transfusion procedure,Pathology,Per Unit,$3.57 ,OP,$3.57 ,$3.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87003,Small animal inoculation,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87015,Specimen infect agnt concntj,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87040,Blood culture for bacteria,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87045,Feces culture aerobic bact,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87046,Stool cultr aerobic bact ea,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87070,Culture othr specimn aerobic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87071,Culture aerobic quant other,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87073,Culture bacteria anaerobic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87075,Cultr bacteria except blood,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87076,Culture anaerobe ident each,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87077,Culture aerobic identify,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87081,Culture screen only,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87084,Culture of specimen by kit,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87086,Urine culture/colony count,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87088,Urine bacteria culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87101,Skin fungi culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87102,Fungus isolation culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87103,Blood fungus culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87106,Fungi identification yeast,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87107,Fungi identification mold,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87109,Mycoplasma,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87110,Chlamydia culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87116,Mycobacteria culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87118,Mycobacteric identification,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87140,Culture type immunofluoresc,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87143,Culture typing glc/hplc,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87147,Culture type immunologic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87149,Dna/rna direct probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87150,Dna/rna amplified probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87152,Culture type pulse field gel,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87158,Culture typing added method,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87164,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87166,Dark field examination,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87168,Macroscopic exam arthropod,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87169,Macroscopic exam parasite,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87172,Pinworm exam,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87176,Tissue homogenization cultr,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87177,Ova and parasites smears,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87181,Microbe susceptible diffuse,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87184,Microbe susceptible disk,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87185,Microbe susceptible enzyme,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87186,Microbe susceptible mic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87187,Microbe susceptible mlc,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87188,Microbe suscept macrobroth,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87190,Microbe suscept mycobacteri,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87197,Bactericidal level serum,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87205,Smear gram stain,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87206,Smear fluorescent/acid stai,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87207,Smear special stain,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87209,Smear complex stain,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87210,Smear wet mount saline/ink,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87220,Tissue exam for fungi,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87230,Assay toxin or antitoxin,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87250,Virus inoculate eggs/animal,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87252,Virus inoculation tissue,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87253,Virus inoculate tissue addl,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87254,Virus inoculation shell via,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87255,Genet virus isolate hsv,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87260,Adenovirus ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87265,Pertussis ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87267,Enterovirus antibody dfa,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87269,Giardia ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87270,Chlamydia trachomatis ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87271,Cytomegalovirus dfa,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87272,Cryptosporidium ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87273,Herpes simplex 2 ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87274,Herpes simplex 1 ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87275,Influenza b ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87276,Influenza a ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87277,Legionella micdadei ag if,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87278,Legion pneumophilia ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87279,Parainfluenza ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87280,Respiratory syncytial ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87281,Pneumocystis carinii ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87283,Rubeola ag if,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87285,Treponema pallidum ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87290,Varicella zoster ag if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87299,Antibody detection nos if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87300,Ag detection polyval if,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87301,Adenovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87305,Aspergillus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87320,Chylmd trach ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87324,Clostridium ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87327,Cryptococcus neoform ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87328,Cryptosporidium ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87329,Giardia ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87332,Cytomegalovirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87335,E coli 0157 ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87336,Entamoeb hist dispr ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87337,Entamoeb hist group ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87338,Hpylori stool ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87339,H pylori ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87340,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87341,Hepatitis b surface ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87350,Hepatitis be ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87380,Hepatitis delta agent ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87385,Histoplasma capsul ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87390,Hiv-1 ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87391,Hiv-2 ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87400,Influenza a/b each ag ia,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87420,Resp syncytial virus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87425,Rotavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87426,Sarscov coronavirus ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87427,Shiga-like toxin ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87428,Sarscov & inf vir a&b ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87430,Strep a ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87449,Nos each organism ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87450,Ag detect nos ia single,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87451,Polyvalent mult org ea ag ia,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87470,Bartonella dna dir probe,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87471,Bartonella dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87472,Bartonella dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87475,Lyme dis dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87476,Lyme dis dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87477,Lyme dis dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87480,Candida dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87481,Candida dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87482,Candida dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87485,Chylmd pneum dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87486,Chylmd pneum dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87487,Chylmd pneum dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87490,Chylmd trach dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87491,Chylmd trach dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87492,Chylmd trach dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87493,C diff amplified probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87495,Cytomeg dna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87496,Cytomeg dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87497,Cytomeg dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87498,Enterovirus probe&revrs trns,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87500,Vanomycin dna amp probe,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87501,Influenza dna amp prob 1+,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87502,Influenza dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87503,Influenza dna amp prob addl,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87510,Gardner vag dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87511,Gardner vag dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87512,Gardner vag dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87515,Hepatitis b dna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87516,Hepatitis b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87517,Hepatitis b dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87520,Hepatitis c rna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87521,Hepatitis c probe&rvrs trnsc,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87522,Hepatitis c revrs trnscrpj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87525,Hepatitis g dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87526,Hepatitis g dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87527,Hepatitis g dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87528,Hsv dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87529,Hsv dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87530,Hsv dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87531,Hhv-6 dna dir probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87532,Hhv-6 dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87533,Hhv-6 dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87534,Hiv-1 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87535,Hiv-1 probe&reverse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87536,Hiv-1 quant&revrse trnscrpj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87537,Hiv-2 dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87538,Hiv-2 probe&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87539,Hiv-2 quant&revrse trnscripj,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87540,Legion pneumo dna dir prob,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87541,Legion pneumo dna amp prob,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87542,Legion pneumo dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87550,Mycobacteria dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87551,Mycobacteria dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87552,Mycobacteria dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87555,M.tuberculo dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87556,M.tuberculo dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87557,M.tuberculo dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87560,M.avium-intra dna dir prob,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87561,M.avium-intra dna amp prob,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87562,M.avium-intra dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87563,M. genitalium amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87580,M.pneumon dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87581,M.pneumon dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87590,N.gonorrhoeae dna dir prob,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87591,N.gonorrhoeae dna amp prob,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87592,N.gonorrhoeae dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87623,Hpv low-risk types,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87624,Hpv high-risk types,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87625,Hpv types 16 & 18 only,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87634,Rsv dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87635,Sars-cov-2 covid-19 amp prb,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87636,Sarscov2 & inf a&b amp prb,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87637,Sarscov2&inf a&b&rsv amp prb,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87640,Staph a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87641,Mr-staph dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87650,Strep a dna dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87651,Strep a dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87652,Strep a dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87653,Strep b dna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87660,Trichomonas vagin dir probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87661,Trichomonas vaginalis amplif,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87662,Zika virus dna/rna amp probe,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87797,Detect agent nos dna dir,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87798,Detect agent nos dna amp,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87799,Detect agent nos dna quant,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87800,Detect agnt mult dna direc,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87801,Detect agnt mult dna ampli,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87802,Strep b assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87803,Clostridium toxin a w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87804,Influenza assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87806,Hiv w/hiv1&2 antb w/optic,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87807,Rsv assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87808,Trichomonas assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87809,Adenovirus assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87810,Chylmd trach assay w/optic,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87811,Sars-cov-2 covid19 w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87850,N. gonorrhoeae assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87880,Strep a assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87899,Agent nos assay w/optic,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87904,Phenotype dna hiv w/clt add,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87905,Sialidase enzyme assay,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,87999,Microbiology procedure,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88104,Cytopath fl nongyn smears,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88106,Cytopath fl nongyn filter,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88108,Cytopath concentrate tech,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88112,Cytopath cell enhance tech,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88120,Cytp urne 3-5 probes ea spec,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88125,Forensic cytopathology,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88130,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88140,Sex chromatin identification,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88141,Cytopath c/v interpret,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88142,Cytopath c/v thin layer,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88143,Cytopath c/v thin layer redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88147,Cytopath c/v automated,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88148,Cytopath c/v auto rescreen,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88150,Cytopath c/v manual,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88152,Cytopath c/v auto redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88153,Cytopath c/v redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88154,Cytopath c/v select,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88155,Cytopath c/v index add-on,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88160,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88161,Cytopath smear other source,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88162,Cytopath smear other source,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88164,Cytopath tbs c/v manual,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88165,Cytopath tbs c/v redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88166,Cytopath tbs c/v auto redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88167,Cytopath tbs c/v select,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88172,Cytp dx eval fna 1st ea site,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88173,Cytopath eval fna report,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88174,Cytopath c/v auto in fluid,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88175,Cytopath c/v auto fluid redo,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88177,Cytp fna eval ea addl,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88182,Cell marker study,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88184,Flowcytometry/ tc 1 marker,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88187,Flowcytometry/read 2-8,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88188,Flowcytometry/read 9-15,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88189,Flowcytometry/read 16 & >,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88199,Cytopathology procedure,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88240,Cell cryopreserve/storage,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88241,Frozen cell preparation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88245,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88248,Chromosome analysis 50-100,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88249,Chromosome analysis 100,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88261,Chromosome analysis 5,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88262,Chromosome analysis 15-20,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88263,Chromosome analysis 45,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88264,Chromosome analysis 20-25,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88267,Chromosome analys placenta,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88269,Chromosome analys amniotic,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88271,Cytogenetics dna probe,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88272,Cytogenetics 3-5,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88273,Cytogenetics 10-30,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88274,Cytogenetics 25-99,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88275,Cytogenetics 100-300,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88280,Chromosome karyotype study,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88283,Chromosome banding study,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88285,Chromosome count additional,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88289,Chromosome study additional,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88291,Cyto/molecular report,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88299,Cytogenetic study,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88300,Surgical path gross,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88302,Tissue exam by pathologist,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88304,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88305,Tissue exam by pathologist,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88311,Decalcify tissue,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88312,Special stains group 1,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88313,Special stains group 2,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88314,Histochemical stains add-on,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88321,Microslide consultation,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88323,Microslide consultation,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88325,Comprehensive review of data,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88329,Path consult introp,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88331,Path consult intraop 1 bloc,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88332,Path consult intraop addl,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88333,Intraop cyto path consult 1,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88334,Intraop cyto path consult 2,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88342,Immunohisto antb 1st stain,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88346,Immunofluor antb 1st stain,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88347,Immunofluorescent study,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88355,Analysis skeletal muscle,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88356,Analysis nerve,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88358,Analysis tumor,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88363,Xm archive tissue molec anal,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88364,Insitu hybridization (fish),Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88369,M/phmtrc alysishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88371,Protein western blot tissue,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88372,Protein analysis w/probe,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88373,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88374,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88375,Optical endomicroscpy interp,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88377,M/phmtrc alys ishquant/semiq,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88380,Microdissection laser,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88381,Microdissection manual,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88387,Tiss exam molecular study,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88388,Tiss ex molecul study add-on,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88399,Surgical pathology procedure,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88720,Bilirubin total transcut,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88738,Hgb quant transcutaneous,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88740,Transcutaneous carboxyhb,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88741,Transcutaneous methb,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,88749,In vivo lab service,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89050,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89051,Body fluid cell count,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89055,Leukocyte assessment fecal,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89060,Exam synovial fluid crystals,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89125,Specimen fat stain,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89160,Exam feces for meat fibers,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89190,Nasal smear for eosinophils,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89220,Sputum specimen collection,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89230,Collect sweat for test,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89240,Pathology lab procedure,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89250,Cultr oocyte/embryo <4 days,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89253,Embryo hatching,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89254,Oocyte identification,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89255,Prepare embryo for transfer,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89257,Sperm identification,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89260,Sperm isolation simple,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89261,Sperm isolation complex,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89264,Identify sperm tissue,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89281,Assist oocyte fertilization,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89290,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89291,Biopsy oocyte polar body,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89300,Semen analysis w/huhner,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89310,Semen analysis w/count,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89320,Semen anal vol/count/mot,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89321,Semen anal sperm detection,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89322,Semen anal strict criteria,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89325,Sperm antibody test,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89329,Sperm evaluation test,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89330,Evaluation cervical mucus,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89331,Retrograde ejaculation anal,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89335,Cryopreserve testicular tiss,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89353,Thawing cryopresrved sperm,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,89398,Unlisted reprod med lab proc,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90287,Botulinum antitoxin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90288,Botulism ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90291,Cmv ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90371,Hep b ig im,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90375,Rabies ig im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90376,Rabies ig heat treated,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90377,Rabies ig ht&sol human im/sc,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90378,Rsv mab im 50mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90384,Rh ig full-dose im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90386,Rh ig iv,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90389,Tetanus ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90393,Vaccina ig im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90396,Varicella-zoster ig im,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90460,Im admin 1st/only component,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90461,Im admin each addl component,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90471,Immunization admin,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90472,Immunization admin each add,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90473,Immune admin oral/nasal,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90474,Immune admin oral/nasal addl,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90476,Adenovirus vaccine type 4,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90477,Adenovirus vaccine type 7,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90581,Anthrax vaccine sc or im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90585,Bcg vaccine percut,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90586,Bcg vaccine intravesical,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90587,Dengue vacc quad 3 dose subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90619,Menacwy-tt vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90620,Menb-4c vacc 2 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90621,Menb-fhbp vacc 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90625,Cholera vaccine live oral,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90630,Flu vacc iiv4 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90632,Hepa vaccine adult im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90633,Hepa vacc ped/adol 2 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90634,Hepa vacc ped/adol 3 dose,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90636,Hep a/hep b vacc adult im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90644,Hib-mency vacc 6wk-18m0 im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90645,Hib vaccine hboc im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90646,Hib vaccine prp-d im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90647,Hib prp-omp vacc 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90648,Hib prp-t vaccine 4 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90649,4vhpv vaccine 3 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90650,2vhpv vaccine 3 dose im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90651,9vhpv vaccine 2/3 dose im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90653,Iiv adjuvant vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90654,Flu vacc iiv3 no preserv id,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90655,Iiv3 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90656,Iiv3 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90657,Iiv3 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90658,Iiv3 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90660,Laiv3 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90661,Cciiv3 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90662,Iiv no prsv increased ag im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90664,Laiv vacc pandemic intranasl,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90666,Flu vac pandem prsrv free im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90667,Iiv vacc pandemic adjuvt im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90668,Iiv vaccine pandemic im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90669,Pneumococcal vacc 7 val im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90670,Pcv13 vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90672,Laiv4 vaccine intranasal,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90673,Riv3 vaccine no preserv im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90674,Cciiv4 vac no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90675,Rabies vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90676,Rabies vaccine id,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90680,Rv5 vacc 3 dose live oral,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90681,Rv1 vacc 2 dose live oral,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90682,Riv4 vacc recombinant dna im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90685,Iiv4 vacc no prsv 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90686,Iiv4 vacc no prsv 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90687,Iiv4 vaccine splt 0.25 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90688,Iiv4 vaccine splt 0.5 ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90689,Vacc iiv4 no prsrv 0.25ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90690,Typhoid vaccine oral,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90691,Typhoid vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90692,Typhoid vaccine h-p sc/id,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90693,Typhoid vaccine akd sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90694,Vacc aiiv4 no prsrv 0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90696,Dtap-ipv vaccine 4-6 yrs im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90697,Dtap-ipv-hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90698,Dtap-ipv/hib vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90700,Dtap vaccine < 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90702,Dt vaccine under 7 yrs im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90703,Tetanus vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90704,Mumps vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90705,Measles vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90706,Rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90707,Mmr vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90708,Measles-rubella vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90710,Mmrv vaccine sc,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90712,Oral poliovirus vaccine,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90713,Poliovirus ipv sc/im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90714,Td vacc no presv 7 yrs+ im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90715,Tdap vaccine 7 yrs/> im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90716,Var vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90717,Yellow fever vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90719,Diphtheria vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90720,Dtp/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90721,Dtap/hib vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90723,Dtap-hep b-ipv vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90725,Cholera vaccine injectable,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90727,Plague vaccine im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90732,Ppsv23 vacc 2 yrs+ subq/im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90733,Mpsv4 vaccine subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90734,Menacwyd/menacwycrm vacc im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90735,Encephalitis vaccine sc,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90736,Hzv vaccine live subq,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90738,Inactivated je vacc im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90739,Hepb vacc 2 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90740,Hepb vacc 3 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90743,Hepb vacc 2 dose adolesc im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90744,Hepb vacc 3 dose ped/adol im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90746,Hepb vaccine 3 dose adult im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90747,Hepb vacc 4 dose immunsup im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90748,Hib-hepb vaccine im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90749,Vaccine toxoid,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90750,Hzv vacc recombinant im,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90756,Cciiv4 vacc abx free im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90785,Psytx complex interactive,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90791,Psych diagnostic evaluation,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90792,Psych diag eval w/med srvcs,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90832,Psytx w pt 30 minutes,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90833,Psytx w pt w e/m 30 min,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90834,Psytx w pt 45 minutes,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90836,Psytx w pt w e/m 45 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90837,Psytx w pt 60 minutes,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90838,Psytx w pt w e/m 60 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90839,Psytx crisis initial 60 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90840,Psytx crisis ea addl 30 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90845,Psychoanalysis,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90846,Family psytx w/o pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90847,Family psytx w/pt 50 min,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90849,Multiple family group psytx,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90853,Group psychotherapy,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90863,Pharmacologic mgmt w/psytx,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90865,Narcosynthesis,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90867,Tcranial magn stim tx plan,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90868,Tcranial magn stim tx deli,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90869,Tcran magn stim redetemine,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90870,Electroconvulsive therapy,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90875,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90876,Psychophysiological therapy,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90880,Hypnotherapy,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90882,Environmental manipulation,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90885,Psy evaluation of records,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90887,Consultation with family,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90889,Preparation of report,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90899,Psychiatric service/therapy,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90901,Biofeedback train any meth,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90911,Biofeedback peri/uro/rectal,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90912,Bfb training 1st 15 min,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90913,Bfb training ea addl 15 min,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90935,Hemodialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90937,Hemodialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90940,Hemodialysis access study,Ancillary Services,Per Unit,$159.07 ,OP,$159.07 ,$159.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90945,Dialysis one evaluation,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90947,Dialysis repeated eval,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90989,Dialysis training complete,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90993,Dialysis training incompl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90997,Hemoperfusion,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,90999,Dialysis procedure,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91010,Esophagus motility study,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91013,Esophgl motil w/stim/perfus,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91020,Gastric motility studies,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91022,Duodenal motility study,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91030,Acid perfusion of esophagus,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91034,Gastroesophageal reflux test,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91035,G-esoph reflx tst w/electrod,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91037,Esoph imped function test,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91038,Esoph imped funct test > 1hr,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91040,Esoph balloon distension tst,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91110,Gi tract capsule endoscopy,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91111,Esophageal capsule endoscopy,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91112,Gi wireless capsule measure,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91117,Colon motility 6 hr study,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91120,Rectal sensation test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91122,Anal pressure record,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91132,Electrogastrography,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91133,Electrogastrography w/test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91200,Liver elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91299,Gastroenterology procedure,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91300,Sarscov2 vac 30mcg/0.3ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91301,Sarscov2 vac 100mcg/0.5ml im,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91302,Coronavirus vaccine 3,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91303,Coronavirus vaccine 4,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91304,Coronavirus vaccine 5,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91305,Coronavirus vaccine 6,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91306,Coronavirus vaccine 7,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91307,Coronavirus vaccine 8,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91308,Coronavirus vaccine 9,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91309,Coronavirus vaccine 10,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,91310,Coronavirus vaccine 11,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92015,Determine refractive state,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92018,New eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92019,Eye exam & treatment,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92020,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92025,Corneal topography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92060,Special eye evaluation,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92065,Orthoptic/pleoptic training,Ancillary Services,Per Unit,$123.52 ,OP,$123.52 ,$123.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92071,Contact lens fitting for tx,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92072,Fit contac lens for managmnt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92081,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92082,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92083,Visual field examination(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92100,Serial tonometry exam(s),Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92132,Cmptr ophth dx img ant segmt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92133,Cmptr ophth img optic nerve,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92134,Cptr ophth dx img post segmt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92136,Ophthalmic biometry,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92140,Glaucoma provocative tests,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92145,Corneal hysteresis deter,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92201,Opscpy extnd rta draw uni/bi,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92202,Opscpy extnd on/mac draw,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92225,Special eye exam initial,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92226,Special eye exam subsequent,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92227,Img rta detcj/mntr ds staff,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92228,Img rta detc/mntr ds phy/qhp,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92229,Img rta detc/mntr ds poc aly,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92230,Eye exam with photos,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92235,Fluorescein angrph uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92240,Icg angiography uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92242,Fluorescein icg angiography,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92250,Eye exam with photos,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92260,Ophthalmoscopy/dynamometry,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92265,Eye muscle evaluation,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92270,Electro-oculography,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92273,Full field erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92274,Multifocal erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92275,Electroretinography,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92283,Color vision examination,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92284,Dark adaptation eye exam,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92285,Eye photography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92286,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92287,Internal eye photography,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92310,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92311,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92312,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92313,Contact lens fitting,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92314,Prescription of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92315,Rx cntact lens aphakia 1 eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92316,Rx cntact lens aphakia 2 eye,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92317,Rx corneoscleral cntact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92325,Modification of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92326,Replacement of contact lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92340,Fit spectacles monofocal,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92341,Fit spectacles bifocal,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92342,Fit spectacles multifocal,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92352,Fit aphakia spectcl monofocl,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92353,Fit aphakia spectcl multifoc,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92354,Fit spectacles single system,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92355,Fit spectacles compound lens,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92358,Aphakia prosth service temp,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92370,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92371,Repair & adjust spectacles,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92499,Eye service or procedure,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92507,Speech/hearing therapy,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92516,Facial nerve function test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92517,Vemp test i&r cervical,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92518,Vemp test i&r ocular,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92519,Vemp tst i&r cervical&ocular,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92520,Laryngeal function studies,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92521,Evaluation of speech fluency,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92522,Evaluate speech production,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92523,Speech sound lang comprehen,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92524,Behavral qualit analys voice,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92534,Optokinetic nystagmus test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92537,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92538,Caloric vstblr test w/rec,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92540,Basic vestibular evaluation,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92543,Caloric vestibular test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92546,Sinusoidal rotational test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92547,Supplemental electrical test,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92548,Cdp-sot 6 cond w/i&r,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92549,Cdp-sot 6 cond w/i&r mct&adt,Otolaryngology,Per Unit,$124.37 ,OP,$124.37 ,$124.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92550,Tympanometry & reflex thresh,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92553,Audiometry air & bone,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92557,Comprehensive hearing test,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92558,Evoked auditory test qual,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92570,Acoustic immitance testing,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92572,Staggered spondaic word test,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92577,Stenger test speech,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92579,Visual audiometry (vra),Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92582,Conditioning play audiometry,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92584,Electrocochleography,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92585,Auditor evoke potent compre,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92586,Auditor evoke potent limit,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92587,Evoked auditory test limited,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92588,Evoked auditory tst complete,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92597,Oral speech device eval,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92601,Cochlear implt f/up exam <7,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92602,Reprogram cochlear implt <7,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92603,Cochlear implt f/up exam 7/>,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92604,Reprogram cochlear implt 7/>,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92605,Ex for nonspeech device rx,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92606,Non-speech device service,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92607,Ex for speech device rx 1hr,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92608,Ex for speech device rx addl,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92610,Evaluate swallowing function,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92618,Ex for nonspeech dev rx add,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92620,Auditory function 60 min,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92621,Auditory function + 15 min,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92625,Tinnitus assessment,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92626,Eval aud funcj 1st hour,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92627,Eval aud funcj ea addl 15,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92630,Aud rehab pre-ling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92633,Aud rehab postling hear loss,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92651,Aep hearing status deter i&r,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92652,Aep thrshld est mlt freq i&r,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92653,Aep neurodiagnostic i&r,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92920,Prq cardiac angioplast 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92921,Prq cardiac angio addl art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92924,Prq card angio/athrect 1 art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92925,Prq card angio/athrect addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92928,Prq card stent w/angio 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92929,Prq card stent w/angio addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92933,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92934,Prq card stent/ath/angio,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92937,Prq revasc byp graft 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92938,Prq revasc byp graft addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92941,Prq card revasc mi 1 vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92943,Prq card revasc chronic 1vsl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92944,Prq card revasc chronic addl,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92950,Heart/lung resuscitation cpr,General Medicine,Per Unit,$385.17 ,OP,$385.17 ,$385.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92953,Temporary external pacing,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92960,Cardioversion electric ext,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92961,Cardioversion electric int,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92971,Cardioassist external,Cardiology,Per Unit,$347.43 ,OP,$347.43 ,$347.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92973,Prq coronary mech thrombect,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92975,Dissolve clot heart vessel,Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92977,Dissolve clot heart vessel,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92978,Endoluminl ivus oct c 1st,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92979,Endoluminl ivus oct c ea,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92986,Revision of aortic valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92987,Revision of mitral valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92990,Revision of pulmonary valve,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92997,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,92998,Pul art balloon repr percut,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93000,Electrocardiogram complete,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93005,Electrocardiogram tracing,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93010,Electrocardiogram report,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93015,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93016,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93017,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93018,Cardiovascular stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93024,Cardiac drug stress test,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93025,Microvolt t-wave assess,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93040,Rhythm ecg with report,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93041,Rhythm ecg tracing,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93042,Rhythm ecg report,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93050,Art pressure waveform analys,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93224,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93225,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93226,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93227,Ecg monit/reprt up to 48 hrs,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93228,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93229,Remote 30 day ecg tech supp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93241,Ext ecg>48hr<7d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93242,Ext ecg>48hr<7d recording,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93243,Ext ecg>48hr<7d scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93244,Ext ecg>48hr<7d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93245,Ext ecg>7d<15d rec scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93246,Ext ecg>7d<15d recording,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93247,Ext ecg>7d<15d scan a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93248,Ext ecg>7d<15d rev&interpj,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93260,Prgrmg dev eval impltbl sys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93261,Interrogate subq defib,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93264,Rem mntr wrls p-art prs snr,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93268,Ecg record/review,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93270,Remote 30 day ecg rev/report,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93271,Ecg/monitoring and analysis,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93272,Ecg/review interpret only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93278,Ecg/signal-averaged,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93279,Prgrmg dev eval pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93280,Pm device progr eval dual,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93281,Pm device progr eval multi,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93282,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93283,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93284,Prgrmg eval implantable dfb,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93285,Prgrmg dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93286,Peri-px eval pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93287,Peri-px device eval & prgr,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93288,Interrog evl pm/ldls pm ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93289,Interrog device eval heart,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93290,Interrog dev eval icpms ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93291,Interrog dev eval scrms ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93292,Wcd device interrogate,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93293,Pm phone r-strip device eval,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93294,Rem interrog evl pm/ldls pm,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93295,Dev interrog remote 1/2/mlt,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93296,Rem interrog evl pm/ids,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93297,Rem interrog dev eval icpms,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93298,Rem interrog dev eval scrms,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93299,Interrog eval icpms/scrms,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93303,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93304,Echo transthoracic,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93306,Tte w/doppler complete,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93307,Tte w/o doppler complete,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93308,Tte f-up or lmtd,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93312,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93313,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93314,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93315,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93316,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93317,Echo transesophageal,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93318,Echo transesophageal intraop,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93320,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93321,Doppler echo exam heart,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93325,Doppler color flow add-on,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93350,Stress tte only,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93351,Stress tte complete,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93352,Admin ecg contrast agent,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93355,Echo transesophageal (tee),Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93356,Myocrd strain img spckl trck,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93451,Right heart cath,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93452,Left hrt cath w/ventrclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93453,R&l hrt cath w/ventriclgrphy,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93454,Coronary artery angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93455,Coronary art/grft angio s&i,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93456,R hrt coronary artery angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93457,R hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93458,L hrt artery/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93459,L hrt art/grft angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93460,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93461,R&l hrt art/ventricle angio,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93462,L hrt cath trnsptl puncture,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93464,Exercise w/hemodynamic meas,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93505,Biopsy of heart lining,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93530,Rt heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93531,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93532,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93533,R & l heart cath congenital,Interventional Cardiology,Per Unit,"$1,389.31 ",OP,"$1,389.31 ","$1,389.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93600,Bundle of his recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93602,Intra-atrial recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93603,Right ventricular recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93609,Map tachycardia add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93610,Intra-atrial pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93612,Intraventricular pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93613,Electrophys map 3d add-on,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93615,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93616,Esophageal recording,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93618,Heart rhythm pacing,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93619,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93620,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93621,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93622,Electrophysiology evaluation,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93623,Stimulation pacing heart,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93624,Electrophysiologic study,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93631,Heart pacing mapping,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93640,Evaluation heart device,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93641,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93642,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93644,Electrophysiology evaluation,Cardiology,Per Unit,"$2,978.06 ",OP,"$2,978.06 ","$2,978.06 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93650,Ablate heart dysrhythm focus,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93653,Ep & ablate supravent arrhyt,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93654,Ep & ablate ventric tachy,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93655,Ablate arrhythmia add on,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93656,Tx atrial fib pulm vein isol,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93657,Tx l/r atrial fib addl,Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93660,Tilt table evaluation,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93662,Intracardiac ecg (ice),Cardiology,Per Unit,"$6,831.73 ",OP,"$6,831.73 ","$6,831.73 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93668,Peripheral vascular rehab,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93701,Bioimpedance cv analysis,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93702,Bis xtracell fluid analysis,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93724,Analyze pacemaker system,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93745,Set-up cardiovert-defibrill,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93750,Interrogation vad in person,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93770,Measure venous pressure,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93784,Ambl bp mntr w/software,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93786,Ambl bp mntr w/sw rec only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93788,Ambl bp mntr w/sw a/r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93790,Ambl bp mntr w/sw i&r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93792,Pt/caregiver traing home inr,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93793,Anticoag mgmt pt warfarin,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93797,Cardiac rehab,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93798,Cardiac rehab/monitor,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93799,Cardiovascular procedure,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93880,Extracranial bilat study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93882,Extracranial uni/ltd study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93886,Intracranial complete study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93888,Intracranial limited study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93890,Tcd vasoreactivity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93892,Tcd emboli detect w/o inj,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93893,Tcd emboli detect w/inj,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93895,Carotid intima atheroma eval,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93922,Upr/l xtremity art 2 levels,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93923,Upr/lxtr art stdy 3+ lvls,Cardiology,Per Unit,$174.07 ,OP,$174.07 ,$174.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93924,Lwr xtr vasc stdy bilat,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93925,Lower extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93926,Lower extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93930,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93931,Upper extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93965,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93970,Extremity study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93971,Extremity study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93975,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93976,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93978,Vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93979,Vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93980,Penile vascular study,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93981,Penile vascular study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93982,Aneurysm pressure sens study,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93985,Dup-scan hemo compl bi std,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93986,Dup-scan hemo compl uni std,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93990,Doppler flow testing,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,93998,Noninvas vasc dx study proc,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94002,Vent mgmt inpat init day,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94003,Vent mgmt inpat subq day,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94004,Vent mgmt nf per day,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94005,Home vent mgmt supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94010,Breathing capacity test,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94011,Spirometry up to 2 yrs old,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94012,Spirmtry w/brnchdil inf-2 yr,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94013,Meas lung vol thru 2 yrs,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94014,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94015,Patient recorded spirometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94016,Review patient spirometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94060,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94070,Evaluation of wheezing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94150,Vital capacity test,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94200,Lung function test (mbc/mvv),Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94250,Expired gas collection,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94375,Respiratory flow volume loop,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94400,Co2 breathing response curve,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94450,Hypoxia response curve,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94452,Hast w/report,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94453,Hast w/oxygen titrate,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94610,Surfactant admin thru tube,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94617,Exercise tst brncspsm w/ecg,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94618,Pulmonary stress testing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94619,Exercise tst brncspsm wo ecg,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94620,Pulmonary stress test/simple,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94621,Cardiopulm exercise testing,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94640,Airway inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94642,Aerosol inhalation treatment,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94644,Cbt 1st hour,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94645,Cbt each addl hour,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94660,Pos airway pressure cpap,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94662,Neg press ventilation cnp,Pulmonary,Per Unit,$417.61 ,OP,$417.61 ,$417.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94664,Evaluate pt use of inhaler,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94667,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94668,Chest wall manipulation,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94669,Mechanical chest wall oscill,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94680,Exhaled air analysis o2,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94681,Exhaled air analysis o2/co2,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94690,Exhaled air analysis,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94726,Pulm funct tst plethysmograp,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94727,Pulm function test by gas,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94728,Airwy resist by oscillometry,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94729,Co/membane diffuse capacity,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94750,Pulmonary compliance study,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94762,Measure blood oxygen level,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94770,Exhaled carbon dioxide test,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94772,Breath recording infant,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94774,Ped home apnea rec compl,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94775,Ped home apnea rec hk-up,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94776,Ped home apnea rec downld,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94777,Ped home apnea rec report,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94780,Cars/bd tst inft-12mo 60 min,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94781,Cars/bd tst inft-12mo +30min,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,94799,Pulmonary service/procedure,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95004,Percut allergy skin tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95012,Exhaled nitric oxide meas,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95017,Perq & icut allg test venoms,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95018,Perq&ic allg test drugs/biol,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95024,Icut allergy test drug/bug,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95027,Icut allergy titrate-airborn,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95028,Icut allergy test-delayed,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95044,Allergy patch tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95052,Photo patch test,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95056,Photosensitivity tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95060,Eye allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95065,Nose allergy test,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95070,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95071,Bronchial allergy tests,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95076,Ingest challenge ini 120 min,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95079,Ingest challenge addl 60 min,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95115,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95117,Immunotherapy injections,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95120,Immunotherapy one injection,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95125,Immunotherapy 2/> injections,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95130,Immntx 1 sting insect,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95131,Immntx 2 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95132,Immntx 3 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95133,Immntx 4 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95134,Immntx 5 sting insects,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95144,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95145,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95146,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95147,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95148,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95149,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95165,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95170,Antigen therapy services,Ancillary Services,Per Unit,$14.01 ,OP,$14.01 ,$14.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95180,Rapid desensitization,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95199,Allergy immunology services,Ancillary Services,Per Unit,$22.49 ,OP,$22.49 ,$22.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95249,Cont gluc mntr pt prov eqp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95250,Cont gluc mntr phys/qhp eqp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95251,Cont gluc mntr analysis i&r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95700,Eeg cont rec w/vid eeg tech,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95705,Eeg w/o vid 2-12 hr unmntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95706,Eeg wo vid 2-12hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95707,Eeg w/o vid 2-12hr cont mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95708,Eeg wo vid ea 12-26hr unmntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95709,Eeg w/o vid ea 12-26hr intmt,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95710,Eeg w/o vid ea 12-26hr cont,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95711,Veeg 2-12 hr unmonitored,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95712,Veeg 2-12 hr intmt mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95713,Veeg 2-12 hr cont mntr,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95714,Veeg ea 12-26 hr unmntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95715,Veeg ea 12-26hr intmt mntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95716,Veeg ea 12-26hr cont mntr,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95717,Eeg phys/qhp 2-12 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95718,Eeg phys/qhp 2-12 hr w/veeg,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95719,Eeg phys/qhp ea incr w/o vid,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95720,Eeg phy/qhp ea incr w/veeg,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95721,Eeg phy/qhp>36<60 hr w/o vid,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95722,Eeg phy/qhp>36<60 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95723,Eeg phy/qhp>60<84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95724,Eeg phy/qhp>60<84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95725,Eeg phy/qhp>84 hr w/o vid,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95726,Eeg phy/qhp>84 hr w/veeg,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95782,Polysom <6 yrs 4/> paramtrs,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95783,Polysom <6 yrs cpap/bilvl,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95803,Actigraphy testing,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95805,Multiple sleep latency test,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95807,Sleep study attended,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95808,Polysom any age 1-3> param,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95810,Polysom 6/> yrs 4/> param,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95811,Polysom 6/>yrs cpap 4/> parm,Pulmonary,Per Unit,$437.56 ,OP,$437.56 ,$437.56 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95812,Eeg 41-60 minutes,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95813,Eeg extnd mntr 61-119 min,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95816,Eeg awake and drowsy,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95819,Eeg awake and asleep,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95822,Eeg coma or sleep only,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95824,Eeg cerebral death only,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95827,Eeg all night recording,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95829,Surgery electrocorticogram,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95836,Ecog impltd brn npgt <30 d,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95857,Cholinesterase challenge,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95860,Muscle test one limb,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95861,Muscle test 2 limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95863,Muscle test 3 limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95864,Muscle test 4 limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95865,Muscle test larynx,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95866,Muscle test hemidiaphragm,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95867,Muscle test cran nerv unilat,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95868,Muscle test cran nerve bilat,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95869,Muscle test thor paraspinal,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95870,Muscle test nonparaspinal,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95872,Muscle test one fiber,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95873,Guide nerv destr elec stim,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95874,Guide nerv destr needle emg,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95875,Limb exercise test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95885,Musc tst done w/nerv tst lim,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95886,Musc test done w/n test comp,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95887,Musc tst done w/n tst nonext,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95905,Motor &/ sens nrve cndj test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95907,Nvr cndj tst 1-2 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95908,Nrv cndj tst 3-4 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95909,Nrv cndj tst 5-6 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95910,Nrv cndj test 7-8 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95911,Nrv cndj test 9-10 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95912,Nrv cndj test 11-12 studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95913,Nrv cndj test 13/> studies,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95921,Autonomic nrv parasym inervj,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95922,Autonomic nrv adrenrg inervj,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95923,Autonomic nrv syst funj test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95924,Ans parasymp & symp w/tilt,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95925,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95926,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95927,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95928,C motor evoked uppr limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95929,C motor evoked lwr limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95930,Visual ep test cns w/i&r,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95933,Blink reflex test,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95937,Neuromuscular junction test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95938,Somatosensory testing,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95939,C motor evoked upr&lwr limbs,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95943,Parasymp&symp hrt rate test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95950,Ambulatory eeg monitoring,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95951,Eeg monitoring/videorecord,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95953,Eeg monitoring/computer,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95954,Eeg monitoring/giving drugs,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95955,Eeg during surgery,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95956,Eeg monitor technol attended,Neurology,Per Unit,$261.51 ,OP,$261.51 ,$261.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95957,Eeg digital analysis,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95958,Eeg monitoring/function test,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95965,Meg spontaneous,Diagnostic Radiology,Per Unit,$221.34 ,OP,$221.34 ,$221.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95966,Meg evoked single,Diagnostic Radiology,Per Unit,$221.34 ,OP,$221.34 ,$221.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95967,Meg evoked each addl,Diagnostic Radiology,Per Unit,$221.34 ,OP,$221.34 ,$221.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95970,Alys npgt w/o prgrmg,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95971,Alys smpl sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95972,Alys cplx sp/pn npgt w/prgrm,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95973,Analyze neurostim complex,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95974,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95975,Cranial neurostim complex,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95976,Alys smpl cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95977,Alys cplx cn npgt prgrmg,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95978,Analyze neurostim brain/1h,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95979,Analyz neurostim brain addon,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95980,Io anal gast n-stim init,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95981,Io anal gast n-stim subsq,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95982,Io ga n-stim subsq w/reprog,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95983,Alys brn npgt prgrmg 15 min,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95984,Alys brn npgt prgrmg addl 15,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,95999,Neurological procedure,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96000,Motion analysis video/3d,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96001,Motion test w/ft press meas,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96002,Dynamic surface emg,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96003,Dynamic fine wire emg,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96020,Functional brain mapping,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96101,Psycho testing by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96102,Psycho testing by technician,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96103,Psycho testing admin by comp,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96105,Assessment of aphasia,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96110,Developmental screen w/score,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96111,Developmental test extend,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96112,Devel tst phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96113,Devel tst phys/qhp ea addl,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96116,Nubhvl xm phys/qhp 1st hr,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96118,Neuropsych tst by psych/phys,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96119,Neuropsych testing by tec,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96120,Neuropsych tst admin w/comp,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96121,Nubhvl xm phy/qhp ea addl hr,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96125,Cognitive test by hc pro,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96127,Brief emotional/behav assmt,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96130,Psycl tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96131,Psycl tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96132,Nrpsyc tst eval phys/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96133,Nrpsyc tst eval phys/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96136,Psycl/nrpsyc tst phy/qhp 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96137,Psycl/nrpsyc tst phy/qhp ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96138,Psycl/nrpsyc tech 1st,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96139,Psycl/nrpsyc tst tech ea,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96146,Psycl/nrpsyc tst auto result,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96150,Assess hlth/behave init,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96151,Assess hlth/behave subseq,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96153,Intervene hlth/behave group,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96154,Interv hlth/behav fam w/pt,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96155,Interv hlth/behav fam no pt,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96156,Hlth bhv assmt/reassessment,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96160,Pt-focused hlth risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96161,Caregiver health risk assmt,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96360,Hydration iv infusion init,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96361,Hydrate iv infusion add-on,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96365,Ther/proph/diag iv inf init,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96366,Ther/proph/diag iv inf addon,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96367,Tx/proph/dg addl seq iv inf,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96368,Ther/diag concurrent inf,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96369,Sc ther infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96370,Sc ther infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96371,Sc ther infusion reset pump,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96413,Chemo iv infusion 1 hr,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96415,Chemo iv infusion addl hr,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96416,Chemo prolong infuse w/pump,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96417,Chemo iv infus each addl seq,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96422,Chemo ia infusion up to 1 hr,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96423,Chemo ia infuse each addl hr,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96425,Chemotherapy infusion method,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96446,Chemotx admn prtl cavity,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96450,Chemotherapy into cns,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96549,Chemotherapy unspecified,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96567,Pdt dstr prmlg les skn,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96570,Photodynmc tx 30 min add-on,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96571,Photodynamic tx addl 15 min,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96573,Pdt dstr prmlg les phys/qhp,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96574,Dbrdmt prmlg les w/pdt,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96900,Ultraviolet light therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96902,Trichogram,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96913,Photochemotherapy uv-a or b,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96920,Laser tx skin < 250 sq cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96921,Laser tx skin 250-500 sq cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96922,Laser tx skin >500 sq cm,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96931,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96932,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96933,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96934,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96935,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96936,Rcm celulr subcelulr img skn,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,96999,Dermatological procedure,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97001,Pt evaluation,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97002,Pt re-evaluation,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97003,Ot evaluation,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97004,Ot re-evaluation,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97010,Hot or cold packs therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97012,Mechanical traction therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97014,Electric stimulation therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97016,Vasopneumatic device therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97018,Paraffin bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97022,Whirlpool therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97024,Diathermy eg microwave,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97026,Infrared therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97028,Ultraviolet therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97032,Electrical stimulation,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97033,Electric current therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97034,Contrast bath therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97035,Ultrasound therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97039,Physical therapy treatment,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97116,Gait training therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97124,Massage therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97139,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97161,Pt eval low complex 20 min,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97162,Pt eval mod complex 30 min,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97163,Pt eval high complex 45 min,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97164,Pt re-eval est plan care,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97165,Ot eval low complex 30 min,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97166,Ot eval mod complex 45 min,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97167,Ot eval high complex 60 min,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97168,Ot re-eval est plan care,Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97535,Self care mngment training,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97545,Work hardening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97546,Work hardening add-on,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97755,Assistive technology assess,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97762,C/o for orthotic/prosth use,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97799,Physical medicine procedure,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97802,Medical nutrition indiv in,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97803,Med nutrition indiv subseq,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97804,Medical nutrition group,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97810,Acupunct w/o stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97811,Acupunct w/o stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97813,Acupunct w/stimul 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,97814,Acupunct w/stimul addl 15m,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98925,Osteopath manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98926,Osteopath manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98927,Osteopath manj 5-6 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98928,Osteopath manj 7-8 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98929,Osteopath manj 9-10 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98940,Chiropract manj 1-2 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98941,Chiropract manj 3-4 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98942,Chiropractic manj 5 regions,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98943,Chiropract manj xtrspinl 1/>,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98960,Self-mgmt educ & train 1 pt,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98961,Self-mgmt educ/train 2-4 pt,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,98962,Self-mgmt educ/train 5-8 pt,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99050,Medical services after hrs,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99051,Med serv eve/wkend/holiday,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99053,Med serv 10pm-8am 24 hr fac,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99058,Office emergency care,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99060,Out of office emerg med serv,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99078,Group health education,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99091,Collj & interpj data ea 30 d,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99100,Special anesthesia service,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99116,Anesthesia with hypothermia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99135,Special anesthesia procedure,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99140,Emergency anesthesia,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99143,Mod sedat phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99144,Mod sedat phys/qhp 5yrs/>,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99145,Mod sedat phys/qhp ea 15 min,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99148,Mod sed diff phys/qhp<5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99149,Mod sed diff phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99150,Mod sed diff phys/qhp add on,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99151,Mod sed same phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99152,Mod sed same phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99153,Mod sed same phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99155,Mod sed oth phys/qhp <5 yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99156,Mod sed oth phys/qhp 5/>yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99157,Mod sed other phys/qhp ea,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99172,Ocular function screen,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99173,Visual acuity screen,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99174,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99175,Induction of vomiting,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99177,Ocular instrumnt screen bil,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99188,App topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99238,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99239,Hospital discharge day,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99363,Anticoagulant mgmt initial,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99364,Anticoagulant mgmt subseq,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99366,Team conf w/pat by hc prof,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99367,Team conf w/o pat by phys,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99368,Team conf w/o pat by hc pro,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99374,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99375,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99377,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99378,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99379,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99380,Nursing fac care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99406,Behav chng smoking 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99407,Behav chng smoking > 10 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99408,Audit/dast 15-30 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99409,Audit/dast over 30 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99439,Chrnc care mgmt svc ea addl,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99453,Rem mntr physiol param setup,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99454,Rem mntr physiol param dev,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99457,Rem physiol mntr 1st 20 min,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99458,Rem physiol mntr ea addl 20,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99465,Nb resuscitation,General Medicine,Per Unit,$385.17 ,OP,$385.17 ,$385.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99473,Self-meas bp pt educaj/train,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99474,Self-meas bp 2 readg bid 30d,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99483,Assmt & care pln pt cog imp,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99484,Care mgmt svc bhvl hlth cond,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99487,Cplx chrnc care 1st 60 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99489,Cplx chrnc care ea addl 30,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99490,Chrnc care mgmt svc 1st 20,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99491,Chrnc care mgmt svc 30 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99492,1st psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99493,Sbsq psyc collab care mgmt,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99494,1st/sbsq psyc collab care,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99495,Trans care mgmt 14 day disch,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99496,Trans care mgmt 7 day disch,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99497,Advncd care plan 30 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99498,Advncd care plan addl 30 min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99503,Home visit resp therapy,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,99504,Home visit mech ventilator,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0001A,Adm sarscov2 30mcg/0.3ml 1st,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0001M,Nfct ds chrnc hcv 6 assays,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0002A,Adm sarscov2 30mcg/0.3ml 2nd,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0002M,Liver dis 10 assays w/ash,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0002U,Onc clrct 3 ur metab alg plp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0003A,Fee covid-19 vac 1 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0003M,Liver dis 10 assays w/nash,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0003U,Onc ovar 5 prtn ser alg scor,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0004A,Fee covid-19 vac 1 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0004M,Scoliosis dna alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0004U,Nfct ds dna 27 resist genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0005U,Onco prst8 3 gene ur alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0006M,Onc hep gene risk classifier,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0006U,Detc ia meds 120+ analytes,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0007M,Onc gastro 51 gene nomogram,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0008M,Onc breast risk score,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0008U,Hpylori detcj abx rstnc dna,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0009M,Fetal aneuploidy trisom risk,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0010M,Onc prostate prob score,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0010U,Nfct ds strn typ whl gen seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0011A,Adm sarscov2 100mcg/0.5ml1st,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0012A,Adm sarscov2 100mcg/0.5ml2nd,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0012U,Germln do gene reargmt detcj,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0013A,Fee covid-19 vac 2 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0013M,Onc mrna 5 gen recr urthl ca,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0013U,Onc sld org neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0014A,Fee covid-19 vac 2 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0014M,Liver ds alys 3 bmrk srm alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0014U,Hem hmtlmf neo gene reargmt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0015M,Adrnl cortcl tum bchm asy 25,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0015U,Rx metab advrs rx rxn dna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0016M,Onc bladder mrna 209 gen alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0017M,Onc dlbcl mrna 20 genes alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0018U,Onc thyr 10 microrna seq alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0019T,Extracorp shock wv tx ms nos,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0019U,Onc rna tiss predict alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0020U,Rx test prsmv ur w/def conf,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0021A,Fee covid-19 vac 3 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0021U,Onc prst8 detcj 8 autoantb,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0022A,Fee covid-19 vac 3 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0022U,Trgt gen seq dna&rna 23 gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0023A,Fee covid-19 vac 3 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0023U,Onc aml dna detcj/nondetcj,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0024A,Fee covid-19 vac 3 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0024U,Glyca nuc mr spectrsc quan,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0025U,Tenofovir liq chrom ur quan,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0026U,Onc thyr dna&mrna 112 genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0027U,Jak2 gene trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0028U,Cyp2d6 gene cpy nmr cmn vrnt,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0029U,Rx metab advrs trgt seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0030U,Rx metab warf trgt seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0031A,Fee covid-19 vac 4 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0031U,Cyp1a2 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0032A,Fee covid-19 vac 4 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0032U,Comt gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0033A,Fee covid-19 vac 4 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0033U,Htr2a htr2c genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0034A,Fee covid-19 vac 4 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0034U,Tpmt nudt15 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0035U,Neuro csf prion prtn qual,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0036U,Xome tum & nml spec seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0037U,Trgt gen seq dna 324 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0038U,Vitamin d srm microsamp quan,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0039U,Dna antb 2strand hi avidity,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0040U,Bcr/abl1 gene major bp quan,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0041A,Fee covid-19 vac 5 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0041U,B brgdrferi antb 5 prtn igm,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0042A,Fee covid-19 vac 5 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0042T,Ct perfusion w/contrast cbf,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0042U,B brgdrferi antb 12 prtn igg,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0043A,Fee covid-19 vac 5 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0043U,Tbrf b grp antb 4 prtn igm,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0044A,Fee covid-19 vac 5 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0044U,Tbrf b grp antb 4 prtn igg,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0045U,Onc brst dux carc is 12 gene,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0046U,Flt3 gene itd variants quan,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0047U,Onc prst8 mrna 17 gene alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0048U,Onc sld org neo dna 468 gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0049U,Npm1 gene analysis quan,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0050U,Trgt gen seq dna 194 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0051A,Fee covid-19 vac 6 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0052A,Fee covid-19 vac 6 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0052U,Lpoprtn bld w/5 maj classes,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0053A,Fee covid-19 vac 6 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0053U,Onc prst8 ca fish alys 4 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0054A,Fee covid-19 vac 6 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0054U,Rx mntr 14+ drugs & sbsts,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0055U,Card hrt trnspl 96 dna seq,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0056U,Hem aml dna gene reargmt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0057U,Onc sld org neo mrna 51 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0058T,Cryopreservation ovary tiss,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0058U,Onc merkel cll carc srm quan,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0059U,Onc merkel cll carc srm +/-,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0060U,Twn zyg gen seq alys chrms2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0061A,Fee covid-19 vac 7 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0062A,Fee covid-19 vac 7 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0063A,Fee covid-19 vac 7 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0063U,Neuro autism 32 amines alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0064A,Fee covid-19 vac 7 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0064U,Antb tp total&rpr ia qual,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0065U,Syfls tst nontreponemal antb,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0066U,Pamg-1 ia cervico-vag fluid,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0069U,Onc clrct microrna mir-31-3p,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0071A,Fee covid-19 vac 8 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0071U,Cyp2d6 full gene sequence,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0072A,Fee covid-19 vac 8 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0073A,Fee covid-19 vac 8 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0074A,Fee covid-19 vac 8 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0074U,Cyp2d6 nonduplicated gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0075T,Perq stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0075U,Cyp2d6 5' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0076T,S&i stent/chest vert art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0076U,Cyp2d6 3' gene dup/mlt,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0077U,Ig paraprotein qual bld/ur,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0078U,Pain mgt opi use gnotyp pnl,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0079U,Cmprtv dna alys mlt snps,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0080U,Onc lng 5 clin rsk factr alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0081A,Fee covid-19 vac 9 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0081U,Onc uveal mlnma mrna 15 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0082A,Fee covid-19 vac 9 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0083A,Fee covid-19 vac 9 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0083U,Onc rspse chemo cntrst tomog,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0084A,Fee covid-19 vac 9 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0084U,Rbc dna gnotyp 10 bld groups,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0085T,Breath test heart reject,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0085U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0086U,Nfct ds bact&fng org id 6+,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0088U,Trnsplj kdn algrft rej 1494,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0089U,Onc mlnma prame & linc00518,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0090U,Onc cutan mlnma mrna 23 gene,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0091A,Fee covid-19 vac 10 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0091U,Onc clrct scr whl bld alg,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0092A,Fee covid-19 vac 10 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0093A,Fee covid-19 vac 10 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0093U,Rx mntr 65 com drugs urine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0094A,Fee covid-19 vac 10 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0094U,Genome rapid sequence alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0095U,Inflm ee elisa alys alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0096U,Hpv hi risk types male urine,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0099T,Implant corneal ring,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0100T,Prosth retina receive&gen,Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0101A,Fee covid-19 vac 11 dose 1,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0101T,Extracorp shockwv tx hi enrg,Orthopedic Surgery,Per Unit,$323.78 ,OP,$323.78 ,$323.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0101U,Hered colon ca do 15 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0102A,Fee covid-19 vac 11 dose 2,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0102U,Hered brst ca rltd do 17 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0103A,Fee covid-19 vac 11 booster,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0103T,Holotranscobalamin,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0103U,Hered ova ca pnl 24 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0104A,Fee covid-19 vac 11 res,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0104U,Hered pan ca pnl 32 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0105U,Neph ckd mult eclia tum nec,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0106T,Touch quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0107T,Vibrate quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0107U,C diff tox ag detcj ia stool,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0108T,Cool quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0109T,Heat quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0109U,Id aspergillus dna 4 species,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0110T,Nos quant sensory test,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0111T,Rbc membranes fatty acids,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0111U,Onc colon ca kras&nras alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0112U,Iadi 16s&18s rrna genes,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0114U,Gi barretts esoph vim&ccna1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0115U,Respir iadna 18 viral&2 bact,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0116U,Rx mntr nzm ia 35+oral flu,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0117U,Pain mgmt 11 endogenous anal,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0118U,Trnsplj don-drv cll-fr dna,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0119U,Crd ceramides liq chrom plsm,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0120U,Onc b cll lymphm mrna 58 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0121U,Sc dis vcam-1 whole blood,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0122U,Sc dis p-selectin whl blood,Laboratory,Per Unit,$6.07 ,OP,$6.07 ,$6.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0123T,Scleral fistulization,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0123U,Mchnl fragility rbc prflg,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0124U,Ftl cgen abnor 3 analytes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0125U,Ftl cgen abnor prnt comp 5,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0126T,Chd risk imt study,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0126U,Ftl cgen abnor prnt comp 5 y,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0127U,Ob pe 3 analytes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0128U,Ob pe 3 analytes y chrmsm,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0129U,Hered brst ca rltd do panel,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0130U,Hered colon ca do mrna pnl,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0131U,Hered brst ca rltd do pnl 13,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0132U,Hered ova ca rltd do pnl 17,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0133U,Hered prst8 ca rltd do 11,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0134U,Hered pan ca mrna pnl 18 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0136U,Atm mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0137U,Palb2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0138U,Brca1 brca2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0139U,Neuro austm meas 6 c metablt,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0140U,Nfct ds fungi dna 15 trgt,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0141U,Nfct ds bact&fng gram pos,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0142U,Nfct ds bact&fng gram neg,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0145U,Drug assay 65+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0146U,Drug assay 80+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0147U,Drug assay 85+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0148U,Drug assay 100+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0149U,Drug assay 60+ rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0151U,Nfct bct/vir resp nfctj 33,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0152U,Nfct ds dna untrgt ngnrj seq,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0153U,Onc breast mrna 101 genes,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0154U,Onc urthl ca rna fgfr3 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0155U,Onc brst ca dna pik3ca gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0156U,Copy number sequence alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0157U,Apc mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0158U,Mlh1 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0159U,Msh2 mrna seq alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0160U,Msh6 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0161U,Pms2 mrna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0162U,Hered colon ca trgt mrna pnl,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0163U,Onc clrct scr 3 prtn alg,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0164U,Gi ibs ia anti-cdtb&vinculin,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0165U,Peanut allg asmt epi,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0166U,Liver ds 10 biochem asy srm,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0167U,Chornc gonadotropin hcg ia,Laboratory,Per Unit,$15.04 ,OP,$15.04 ,$15.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0168U,Ftl aneuploidy dna seq alys,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0169U,Nudt15&tpmt gene com vrnt,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0170U,Neuro asd rna next gen seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0171U,Trgt gen seq alys pnl dna 23,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0172T,Lumbar spine process addl,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0172U,Onc sld tum alys brca1 brca2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0173U,Psyc gen alys panel 14 genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0174U,Onc solid tumor 30 prtn trgt,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0175U,Psyc gen alys panel 15 genes,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0176U,Cdtb&vinculin igg antb ia,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0177U,Onc brst ca dna pik3ca 11,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0178T,64 lead ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0178U,Peanut allg asmt epi clin rx,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0179T,64 lead ecg w/tracing,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0179U,Onc nonsm cll lng ca alys 23,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0180U,Abo gnotyp abo 7 exons,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0181U,Co gnotyp aqp1 exon 1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0182T,Hdr elect brachytherapy,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0182U,Crom gnotyp cd55 exons 1-10,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0183U,Di gnotyp slc4a1 exon 19,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0184T,Exc rectal tumor endoscopic,General Surgery,Per Unit,"$1,129.81 ",OP,"$1,129.81 ","$1,129.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0184U,Do gnotyp art4 exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0185U,Fut1 gnotyp fut1 exon 4,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0186U,Fut2 gnotyp fut2 exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0188U,Ge gnotyp gypc exons 1-4,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0191T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0191U,In gnotyp cd44 exons 2 3 6,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0192U,Jk gnotyp slc14a1 exon 9,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0194U,Kel gnotyp kel exon 8,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0195U,Klf1 targeted sequencing,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0196U,Lu gnotyp bcam exon 3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0197U,Lw gnotyp icam4 exon 1,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0198T,Ocular blood flow measure,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0199U,Sc gnotyp ermap exons 4 12,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0200U,Xk gnotyp xk exons 1-3,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0201U,Yt gnotyp ache exon 2,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0203U,Ai ibd mrna xprsn prfl 17,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0204U,Onc thyr mrna xprsn alys 593,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0205T,Inirs each vessel add-on,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0205U,Oph amd alys 3 gene variants,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0206T,Cptr dbs alys car elec dta,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0206U,Neuro alzheimer cell aggregj,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0207T,Clear eyelid gland w/heat,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0207U,Neuro alzheimer quan imaging,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0208U,Onc mtc mrna xprsn alys 108,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0209U,Cytog const alys interrog,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0210U,Syphilis tst antb ia quan,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0211U,Onc pan-tum dna&rna gnrj seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0212T,Compre audiometry evaluation,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0212U,Rare ds gen dna alys proband,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0213U,Rare ds gen dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0214U,Rare ds xom dna alys proband,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0215T,Njx paravert w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0215U,Rare ds xom dna alys ea comp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0216U,Neuro inh ataxia dna 12 com,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0217U,Neuro inh ataxia dna 51 gene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0218U,Neuro musc dys dmd seq alys,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0219U,Nfct agt hiv gnrj seq alys,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0220U,Onc brst ca ai assmt 12 feat,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0221U,Abo gnotyp next gnrj seq abo,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0222U,Rhd&rhce gntyp next gnrj seq,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0223T,Acoustic ecg w/i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0224T,Acoustic ecg 1+ analysis,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0224U,Antibody sars-cov-2 titer(s),Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0225T,Acoustic ecg analy & reprog,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0226U,Svnt sarscov2 elisa plsm srm,Laboratory,Per Unit,$9.92 ,OP,$9.92 ,$9.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0227U,Rx asy prsmv30+rx/metablt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0228T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0228U,Onc prst8 ma molec prfl alg,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0229T,Njx tfrml eprl w/us cer/thor,Neurology,Per Unit,$454.82 ,OP,$454.82 ,$454.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0229U,Bcat1 promoter mthyltn alys,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0230U,Ar full sequence analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0231U,Cacna1a full gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0232T,Njx platelet plasma,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0232U,Cstb full gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0233T,Skin glycation spectroscopy,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0233U,Fxn gene analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0234U,Mecp2 full gene analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0235T,Trluml perip athrc visceral,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0235U,Pten full gene analysis,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0236T,Trluml perip athrc abd aorta,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0236U,Smn1&smn2 full gene analysis,Laboratory,Per Unit,$74.24 ,OP,$74.24 ,$74.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0237T,Trluml perip athrc brchiocph,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0237U,Car ion chnlpthy gen seq pnl,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0238T,Trluml perip athrc iliac art,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0238U,Onc lnch syn gen dna seq aly,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0239U,Trgt gen seq alys pnl 311+,Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0240T,Esoph motility 3d topography,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0241T,Esoph motility w/stim/perf,Gastroenterology,Per Unit,$343.37 ,OP,$343.37 ,$343.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0243T,Intm msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0244T,Cont msr bronchodil wheeze,Pulmonary,Per Unit,$130.30 ,OP,$130.30 ,$130.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0249T,Ligation hemorrhoid w/us,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0253T,Insert aqueous drain device,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0255T,Evasc rpr iliac art bifr s&i,Vascular Surgery,Per Unit,"$1,375.47 ",OP,"$1,375.47 ","$1,375.47 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0263T,Im b1 mrw cel ther cmpl,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0264T,Im b1 mrw cel ther xcl hrvst,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0265T,Im b1 mrw cel ther hrvst onl,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0266T,Implt/rpl crtd sns dev total,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0267T,Implt/rpl crtd sns dev lead,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0268T,Implt/rpl crtd sns dev gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0269T,Rev/remvl crtd sns dev total,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0270T,Rev/remvl crtd sns dev lead,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0271T,Rev/remvl crtd sns dev gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0272T,Interrogate crtd sns dev,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0273T,Interrogate crtd sns w/pgrmg,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0278T,Tempr,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0282T,Periph field stimul trial,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0283T,Periph field stimul perm,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0284T,Periph field stimul revise,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0285T,Periph field stimul analys,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0286T,Near ifr spectrsc of wounds,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0288T,Anoscopy w/rf delivery,General Surgery,Per Unit,$798.86 ,OP,$798.86 ,$798.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0289T,Laser inc for pkp/lkp donor,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0290T,Laser inc for pkp/lkp recip,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0294T,Ins lt atrl mont pres lead,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0295T,Ext ecg complete,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0296T,Ext ecg recording,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0297T,Ext ecg scan w/report,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0298T,Ext ecg review and interp,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0301T,Mw therapy for breast tumor,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0302T,Icar ischm mntrng sys compl,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0303T,Icar ischm mntrng sys eltrd,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0304T,Icar ischm mntrng sys device,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0305T,Icar ischm mntrng prgrm eval,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0306T,Icar ischm mntr interr eval,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0307T,Rmvl icar ischm mntrng dvce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0308T,Insj ocular telescope prosth,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0310T,Motor function mapping ntms,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0311T,Cal & alys cntrl artl press,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0312T,Laps impltj nstim vagus,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0313T,Laps rmvl nstim array vagus,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0314T,Laps rmvl vgl arry&pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0315T,Rmvl vagus nerve pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0316T,Replc vagus nerve pls gen,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0317T,Elec alys vagus nrv pls gen,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0329T,Mntr io press 24hrs/> uni/bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0330T,Tear film img uni/bi w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0331T,Heart symp image plnr,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0332T,Heart symp image plnr spect,Diagnostic Nuclear Medicine,Per Unit,$525.42 ,OP,$525.42 ,$525.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0333T,Visual ep scr acuity auto,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0335T,Insj sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0337T,Endothel fxnassmnt non-invas,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0341T,Quant pupillometry w/ rprt,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0342T,Thxp apheresis w/hdl delip,Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0346T,Ultrasound elastography,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0348T,Rsa spine exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0349T,Rsa upper extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0350T,Rsa lower extr exam,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0352T,Oct brst/node i&r per spec,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0354T,Oct breast surg cavity i&r,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0355T,Gi tract capsule endoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0356T,Insrt drug device for iop,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0357T,Cryopreservation oocyte(s),Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0358T,Bia whole body,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0362T,Bhv id suprt assmt ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0373T,Adapt bhv tx ea 15 min,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0376T,Insert ant segment drain int,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0377T,Anoscpy inj agent for incont,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0378T,Visual field assmnt rev/rprt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0379T,Vis field assmnt tech suppt,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0380T,Comp animat ret imag series,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0381T,Ext h rate epi sz 14 days,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0382T,Ext h rate sz 14 day ri only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0383T,Ext h rate sz up to 30 days,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0384T,Ex h rate sz 30 day ri only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0385T,Ex h rate for sz ovr 30 day,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0386T,Ex h rate sz 30+ day ri only,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0387T,Leadless c pm ins/rpl ventr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0388T,Leadless c pm remove ventr,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0389T,Prog eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0390T,Periproc eval inper ledls pm,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0391T,Intergt eval inper leadls pm,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0392T,Lap es sph augment dev place,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0393T,Es sph augmnt device removal,General Surgery,Per Unit,"$2,104.05 ",OP,"$2,104.05 ","$2,104.05 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0394T,Hdr elctrnc skn surf brchytx,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0395T,Hdr elctr ntrst/ntrcv brchtx,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0398T,Mrgfus strtctc les abltj,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0399T,Myocardial strain imaging,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0400T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0401T,Mltispectrl digital les alys,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0402T,Colgn cross-link crn med sep,Ophthalmology Surgery,Per Unit,$345.84 ,OP,$345.84 ,$345.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0403T,Diabetes prev standard curr,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0406T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0407T,Sin ndsc plmt drg elut mplnt,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0408T,Insj/rplc cardiac modulj sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0409T,Insj/rplc car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0412T,Rmvl cardiac modulj pls gen,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0414T,Rmvl & rpl car modulj pls gn,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0417T,Prgrmg eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0418T,Interro eval cardiac modulj,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0419T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0420T,Dstrj neurofibroma xtnsv,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0421T,Waterjet prostate abltj cmpl,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0422T,Tactile breast img uni/bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0423T,Assay secretory type ii pla2,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0424T,Insj/rplc nstim apnea compl,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0425T,Insj/rplc nstim apnea sen ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0426T,Insj/rplc nstim apnea stm ld,Neurological Surgery,Per Unit,"$2,795.98 ",OP,"$2,795.98 ","$2,795.98 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0427T,Insj/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0428T,Rmvl nstim apnea pls gen,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0429T,Rmvl nstim apnea sen ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0430T,Rmvl nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0431T,Rmvl/rplc nstim apnea pls gn,Neurological Surgery,Per Unit,"$7,098.75 ",OP,"$7,098.75 ","$7,098.75 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0432T,Repos nstim apnea stimj ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0433T,Repos nstim apnea sensing ld,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0434T,Interro eval npgs apnea,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0435T,Prgrmg eval npgs apnea 1 ses,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0436T,Prgrmg eval npgs apnea study,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0437T,Impltj synth rnfcmt abdl wal,General Surgery,Per Unit,"$1,330.49 ",OP,"$1,330.49 ","$1,330.49 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0438T,Tprnl plmt biodegrdabl matrl,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0439T,Myocrd contrast prfuj echo,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0440T,Abltj perc uxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0441T,Abltj perc lxtr/perph nrv,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0442T,Abltj perc plex/trncl nrv,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0443T,R-t spctrl alys prst8 tiss,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0446T,Insj impltbl glucose sensor,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0447T,Rmvl impltbl glucose sensor,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0448T,Remvl insj impltbl gluc sens,General Surgery,Per Unit,$367.48 ,OP,$367.48 ,$367.48 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0449T,Insj aqueous drain dev 1st,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0450T,Insj aqueous drain dev each,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0453T,Insj/rplcmt mech-elec ntrfce,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0457T,Remvl mech-elec skin ntrfce,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0462T,Prgrmg eval aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0463T,Interrog aortic ventr sys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0464T,Visual ep test for glaucoma,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0466T,Insj ch wal respir eltrd/ra,Neurological Surgery,Per Unit,"$12,849.88 ",OP,"$12,849.88 ","$12,849.88 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0467T,Revj/rplmnt ch respir eltrd,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0468T,Rmvl ch wal respir eltrd/ra,Neurological Surgery,Per Unit,$610.14 ,OP,$610.14 ,$610.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0469T,Rta polarize scan oc scr bi,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0470T,Oct skn img acquisj i&r 1st,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0471T,Oct skn img acquisj i&r addl,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0472T,Prgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0473T,Reprgrmg io rta eltrd ra,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0474T,Insj aqueous drg dev io rsvr,Ophthalmology Surgery,Per Unit,"$1,563.30 ",OP,"$1,563.30 ","$1,563.30 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0475T,Rec ftl car sgl 3 ch i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0476T,Rec ftl car sgl elec tr data,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0477T,Rec ftl car sgl xrtj alys,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0478T,Rec ftl car 3 ch rev i&r,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0481T,Njx autol wbc concentrate,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0482T,Absl quan myocrd bld flo pet,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0485T,Oct mid ear i&r unilateral,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0486T,Oct mid ear i&r bilateral,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0487T,Trvg biomchn mapg w/reprt,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0488T,Diabetes prev online/elec,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0489T,Regn cell tx scldr hands,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0490T,Regn cell tx scldr h mlt inj,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0497T,Xtrnl pt act ecg in-off conn,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0498T,Xtrnl pt act ecg r&i pr 30 d,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0499T,Cysto f/urtl strix/stenosis,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0500T,Hpv 5+ hi risk hpv types,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0501T,Cor ffr derived cor cta data,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0502T,Cor ffr data prep & transmis,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0503T,Cor ffr alys gnrj ffr mdl,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0504T,Cor ffr data review i&r,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0505T,Ev fempop artl revsc,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0506T,Mac pgmt opt dns meas hfp,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0507T,Near ifr 2img mibmn glnd i&r,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0508T,Pls echo us b1 dns meas tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0509T,Pattern erg w/i&r,Ophthalmology,Per Unit,$200.58 ,OP,$200.58 ,$200.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0510T,Rmvl sinus tarsi implant,Orthopedic Surgery,Per Unit,"$1,076.12 ",OP,"$1,076.12 ","$1,076.12 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0511T,Rmvl&rinsj sinus tarsi implt,Orthopedic Surgery,Per Unit,"$2,502.66 ",OP,"$2,502.66 ","$2,502.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0514T,Intraop vis axis id pt fixj,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0515T,Insj wcs lv compl sys,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0517T,Insj wcs lv pg compnt,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0518T,Rmvl pg compnt wcs,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0519T,Rmvl & rplcmt pg compnt wcs,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0520T,Rmvl&rplcmt pg wcs new eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0521T,Interrog dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0522T,Prgrmg dev eval wcs ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0525T,Insj/rplcmt compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0527T,Insj/rplcmt iims implt mntr,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0528T,Prgrmg dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0529T,Interrog dev eval iims ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0530T,Removal complete iims,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0532T,Removal iims implt mntr only,Interventional Cardiology,Per Unit,"$3,320.20 ",OP,"$3,320.20 ","$3,320.20 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0533T,Cont rec mvmt do 6-10 days,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0534T,Cont rec mvmt do setup&train,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0535T,Cont rec mvmt do reprt cnfig,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0536T,Cont rec mvmt do dl w/i&r,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0541T,Myocardial imaging mcg,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0542T,Myocardial imaging mcg i&r,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0546T,Rf spectrsc ntraop mrgn asmt,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0547T,B1 matrl qual tst mcrind tib,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0548T,Tprnl balo cntnc dev bi,Urological Surgery,Per Unit,"$2,714.29 ",OP,"$2,714.29 ","$2,714.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0549T,Tprnl balo cntnc dev uni,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0550T,Tprnl balo cntnc dev rmvl ea,Urological Surgery,Per Unit,$834.13 ,OP,$834.13 ,$834.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0551T,Tprnl balo cntnc dev adjmt,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0552T,Low-level laser therapy,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0553T,Perq tcat iliac anast implt,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0554T,B1 str & fx rsk analysis,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0556T,B1 str & fx rsk assessment,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0558T,Ct scan f/biomchn ct alys,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0563T,Evac meibomian glnd heat bi,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0564T,Onc chemo rx cytotox csc 14,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0566T,Autol cell implt adps njx,Orthopedics,Per Unit,$184.59 ,OP,$184.59 ,$184.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0568T,Intro mix saline&air f/ssg,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0571T,Insj/rplcmt icds ss eltrd,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0575T,Prgrmg dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0576T,Interrog dev eval icds ss ip,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0577T,Ephys eval icds ss,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0578T,Rem interrog dev icds phys,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0579T,Rem interrog dev icds tech,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0581T,Abltj mal brst tum perq crtx,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0582T,Trurl abltj mal prst8 tiss,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0583T,Tmpst auto tube dlvr sys,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0587T,Perq impltj/rplcmt isdns ptn,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0588T,Revision/removal isdns ptn,Neurology,Per Unit,$250.78 ,OP,$250.78 ,$250.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0589T,Elec alys smpl prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0590T,Elec alys cplx prgrmg iins,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0591T,Hlth&wb coaching indiv 1st,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0592T,Hlth&wb coaching indiv f-up,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0593T,Hlth&wb coaching group,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0596T,Temp fml iu vlv-pmp 1st insj,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0597T,Temp fml iu valve-pmp rplcmt,Urology,Per Unit,$236.52 ,OP,$236.52 ,$236.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0602T,Transdermal gfr measurements,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0603T,Transdermal gfr monitoring,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0604T,Rem oct rta dev setup&educaj,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0605T,Rem oct rta techl sprt min 8,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0607T,Rem mntr pulm flu mntr setup,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0608T,Rem mntr pulm flu mntr alys,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0609T,Mrs disc pain acquisj data,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0610T,Mrs disc pain transmis data,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0611T,Mrs disc pain alg alys data,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0614T,Rmvl&rplcmt ss impl dfb pg,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0615T,Eye mvmt alys w/o calbrj i&r,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0616T,Insertion of iris prosthesis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0617T,Insj iris prosth w/rmvl&insj,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0618T,Insj iris prosth sec io lens,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0619T,Cysto w/prst8 commissurotomy,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0620T,Evasc ven artlz tibl/prnl vn,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0621T,Trabeculostomy interno laser,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0622T,Trabeculostomy int lsr w/scp,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0623T,Auto quantification c plaque,Cardiology,Per Unit,$144.45 ,OP,$144.45 ,$144.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0632T,Perq tcat us abltj nrv p-art,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0633T,Ct breast w/3d uni c-,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0634T,Ct breast w/3d uni c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0635T,Ct breast w/3d uni c-/c+,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0636T,Ct breast w/3d bi c-,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0637T,Ct breast w/3d bi c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0638T,Ct breast w/3d bi c-/c+,Diagnostic Radiology,Per Unit,$179.12 ,OP,$179.12 ,$179.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,0639T,Wrls skn snr anisotropy meas,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C1762,"Conn tiss, human(inc fascia)",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C1763,"Conn tiss, non-human",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C1849,"Skin substitute, synthetic",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C1878,Matrl for vocal cord,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C2615,"Sealant, pulmonary, liquid",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8900,"Mra w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8901,"Mra w/o cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8902,"Mra w/o fol w/cont, abd",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8903,"Mri w/cont, breast, uni",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8904,"Mri w/o cont, breast, uni",Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8905,"Mri w/o fol w/cont, brst, un",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8906,"Mri w/cont, breast, bi",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8907,"Mri w/o cont, breast, bi",Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8908,"Mri w/o fol w/cont, breast,",Diagnostic Radiology,Per Unit,$271.57 ,OP,$271.57 ,$271.57 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8909,"Mra w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8910,"Mra w/o cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8911,"Mra w/o fol w/cont, chest",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8912,"Mra w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8913,"Mra w/o cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8914,"Mra w/o fol w/cont, lwr ext",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8918,"Mra w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8919,"Mra w/o cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8920,"Mra w/o fol w/cont, pelvis",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8921,"Tte w or w/o fol w/cont, com",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8922,"Tte w or w/o fol w/cont, f/u",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8923,"2d tte w or w/o fol w/con,co",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8924,"2d tte w or w/o fol w/con,fu",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8925,"2d tee w or w/o fol w/con,in",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8926,"Tee w or w/o fol w/cont,cong",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8927,"Tee w or w/o fol w/cont, mon",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8928,"Tte w or w/o fol w/con,stres",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8929,"Tte w or wo fol wcon,doppler",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8930,"Tte w or w/o contr, cont ecg",Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8931,"Mra, w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8932,"Mra, w/o dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8933,"Mra, w/o&w/dye, spinal canal",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8934,"Mra, w/dye, upper extremity",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8935,"Mra, w/o dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8936,"Mra, w/o&w/dye, upper extr",Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C8957,"Prolonged iv inf, req pump",General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9014,"Injection, cerliponase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9015,"C-1 esterase, haegarda",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9016,"Inj, triptorelin ext rel",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9024,"Inj, daunorubicin-cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9025,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9026,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9027,"Injection, pembrolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9028,Inj. inotuzumab ozogamicin,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9029,"Injection, guselkumab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9030,Inj copanlisib,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9031,"Lutetium Lu 177 dotatate, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9032,Voretigene neparvovec-rzyl,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9033,"Inj, akynzeo",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9034,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9035,"Injection, Aristada Initio",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9036,"Injection, patisiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9037,"Injection, risperidone",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9038,Inj mogamulizumab-kpkc,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9040,"Injection, fremanezumab-vfrm",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9041,"Inj, coagulation factor xa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9042,"Inj., belrapzo 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9043,"Injection, levoleucovorin",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9044,"Injection, cemiplimab-rwlc",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9045,Moxetumomab pasudotox-tdfk,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9047,"Injection, caplacizumab-yhdp",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9048,Dexamethasone ophth insert,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9049,"Injection, tagraxofusp-erzs",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9050,"Injection, emapalumab-lzsg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9051,"Injection, omadacycline",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9052,"Injection, ravulizumab-cwv",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9053,"Inj, crizanlizumab-tmca",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9054,"Injection, lefamulin",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9055,"Inj, brexanolone",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9056,"Injection, givosiran",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9057,Inj cetirizine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9058,"Injection,pegfilgrastim-bmez",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9059,"Injection, meloxicam",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9061,"Injection, teprotumumab-trbw",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9062,Daratumumab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9063,"Injection, eptinezumab-jjmr",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9064,Mitomycin pyelocalyceal inst,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9065,Romidepsin non-lyophilized,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9066,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9069,Belantamab mafodontin-blmf,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9070,"Injection, tafasitamab-cxix",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9071,"Injection, viltolarsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9072,"Inj, imm glob asceniv",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9121,"Injection, argatroban",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9122,Mometasone furoate (sinuva),Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9132,"Kcentra, per i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9137,Adynovate Factor VIII recom,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9138,Nuwiq Factor VIII recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9139,"Idelvion, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9140,Afstyla factor viii recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9141,Factor viii pegylated-aucl,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9248,"Inj, clevidipine butyrate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9250,Artiss fibrin sealant,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9257,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9293,"Injection, glucarpidase",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9349,"Puraply, puraply antimic",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9352,"Neuragen nerve guide, per cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9353,"Neurawrap nerve protector,cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9354,"Veritas collagen matrix, cm2",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9355,"Neuromatrix nerve cuff, cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9356,"Tenoglide tendon prot, cm2",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9358,"Surgimend, fetal",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9359,"Implnt,bon void filler-putty",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9360,"Surgimend, neonatal",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9361,Neuromend nerve wrap,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9362,"Implnt,bon void filler-strip",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9363,Integra meshed bil wound mat,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9364,"Porcine implant, permacol",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9408,"Iodine i-131 iobenguane, tx",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9442,"Injection, belinostat",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9443,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9444,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9445,"C-1 esterase, Ruconest",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9446,"Inj, tedizolid phosphate",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9447,"Inj, phenylephrine ketorolac",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9448,Oral netupitant palonosetron,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9449,"Inj, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9450,Fluocinolone acetonide implt,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9451,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9452,"Inj, ceftolozane/tazobactam",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9453,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9454,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9455,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9456,"Inj, isavuconazonium sulfate",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9460,"Injection, cangrelor",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9465,"Injection, Durolane",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9466,"Injection, benralizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9467,Inj rituximab hyaluronidase,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9468,"Inj, factor ix, Rebinyn",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9469,Inj triamcinolone acetonide,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9470,Aripiprazole lauroxil im,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9471,"Hymovis, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9472,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9473,"Injection, mepolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9474,"Inj, irinotecan liposome",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9475,"Injection, necitumumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9476,"Injection, daratumumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9477,"Injection, elotuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9478,"Injection, sebelipase alfa",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9480,"Injection, trabectedin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9481,"Injection, reslizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9482,Sotalol hydrochloride iv,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9483,"Injection, atezolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9484,"Injection, eteplirsen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9485,"Injection, olaratumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9487,"Ustekinumab IV inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9488,Conivaptan hcl,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9489,"Injection, nusinersen",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9490,"Injection, bezlotoxumab",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9491,"Injection, avelumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9492,"Injection, durvalumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9493,"Injection, edaravone",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9494,"Injection, ocrelizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9497,"Loxapine, inhalation powder",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9600,Perc drug-el cor stent sing,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9601,Perc drug-el cor stent bran,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9602,Perc d-e cor stent ather s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9603,Perc d-e cor stent ather br,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9604,Perc d-e cor revasc t cabg s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9605,Perc d-e cor revasc t cabg b,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9606,Perc d-e cor revasc w ami s,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9607,Perc d-e cor revasc chro sin,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9608,Perc d-e cor revasc chro add,Interventional Cardiology,Per Unit,"$4,903.27 ",OP,"$4,903.27 ","$4,903.27 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9724,Eps stomach plic,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9726,Rxt breast appl place/remov,General Surgery,Per Unit,$702.95 ,OP,$702.95 ,$702.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9728,"Place device/marker, non pro",Therapeutic Radiology,Per Unit,$68.45 ,OP,$68.45 ,$68.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9734,"U/s trtmt, not leiomyomata",General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9737,Lap esoph augmentation,General Surgery,Per Unit,"$3,851.80 ",OP,"$3,851.80 ","$3,851.80 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9739,Cystoscopy prostatic imp 1-3,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9740,Cysto impl 4 or more,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9741,Impl pressure sensor w/angio,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9742,Laryngoscopy with injection,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9743,Bulking/spacer material impl,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9744,Abd us w/contrast,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9745,Nasal endo eustachian tube,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9747,"Ablation, hifu, prostate",Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9749,Repair nasal stenosis w/imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9750,Ins/rem-replace compl iims,Interventional Cardiology,Per Unit,"$4,587.29 ",OP,"$4,587.29 ","$4,587.29 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9762,Cardiac mri seg dys strain,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9763,Cardiac mri seg dys stress,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9765,Revasc intra lithotrip-stent,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9767,Revasc lithotrip-stent-ather,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9768,Endo us-guide hep porto grad,Gastroenterology,Per Unit,$616.04 ,OP,$616.04 ,$616.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9769,Cysto w/temp pros implant,Urological Surgery,Per Unit,"$1,672.81 ",OP,"$1,672.81 ","$1,672.81 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9770,"Vitrec/mech pars, subret inj",Ophthalmology Surgery,Per Unit,"$1,690.18 ",OP,"$1,690.18 ","$1,690.18 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9771,Nsl/sins cryo post nasal tis,Otolaryngology Surgery,Per Unit,"$1,674.71 ",OP,"$1,674.71 ","$1,674.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9772,Revasc lithotrip tibi/perone,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9773,Revasc lithotr-stent tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9774,Revasc lithotr-ather tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9775,Revasc lith-sten-ath tib/per,Interventional Radiology,Per Unit,"$2,821.82 ",OP,"$2,821.82 ","$2,821.82 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,C9803,Hopd covid-19 spec collect,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0120,Periodic oral evaluation,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0140,Limit oral eval problm focus,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0145,"Oral evaluation, pt < 3yrs",Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0150,Comprehensve oral evaluation,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0160,Extensv oral eval prob focus,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0170,"Re-eval,est pt,problem focus",Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0171,Re-eval post-op visit,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0180,Comp periodontal evaluation,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0190,Screening of a patient,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0191,Assessment of a patient,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0210,Intraor complete film series,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0220,Intraoral periapical first,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0230,Intraoral periapical ea add,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0240,Intraoral occlusal film,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0250,Extraoral 2d project image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0251,Extraoral posterior image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0260,Extraoral ea additional film,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0270,Dental bitewing single image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0272,Dental bitewings two images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0273,Bitewings - three images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0274,Bitewings four images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0277,Vert bitewings 7 to 8 images,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0290,Skull/facial bone image,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0310,Dental saliography,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0320,Dental tmj arthrogram incl i,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0321,Other tmj images by report,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0322,Dental tomographic survey,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0330,Panoramic image,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0340,2d cephalometric image,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0350,Oral/facial photo images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0351,3d photographic image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0364,Cone beam ct capt & interp,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0365,Cone beam ct interprete man,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0366,Cone beam ct interprete max,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0367,Cone beam ct interp both jaw,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0368,Cone beam ct interprete tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0369,Max mri capture & interprete,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0370,Max ultrasound capt & interp,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0371,Sialoendoscopy capt & interp,Dental,Per Unit,$87.62 ,OP,$87.62 ,$87.62 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0380,Cone beam ct capture limited,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0381,Cone beam ct capt mandible,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0382,Cone beam ct capt maxilla,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0383,Cone beam ct both jaws,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0384,Cone beam ct capture tmj,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0385,Max mri image capture,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0386,Max ultrasound image capture,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0391,Imterprete diagnostic image,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0393,Trtmnt simulation 3d image,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0394,Digital sub 2 or more images,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0395,Fusion 2 or more 3d images,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0411,Hba1c in office testing,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0412,Blood glucose level test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0414,Lab process microbial spec,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0415,Collection of microorganisms,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0416,Viral culture,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0418,Analysis of saliva sample,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0419,Assess of salivary flow,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0421,Gen tst suscept oral disease,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0422,Collect & prep genetic samp,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0423,Genetic test spec analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0425,Caries susceptibility test,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0431,Diag tst detect mucos abnorm,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0460,Pulp vitality test,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0470,Diagnostic casts,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0472,"Gross exam, prep & report",Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0473,"Micro exam, prep & report",Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0474,Micro w exam of surg margins,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0475,Decalcification procedure,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0476,Spec stains for microorganis,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0477,Spec stains not for microorg,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0478,Immunohistochemical stains,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0479,Tissue in-situ hybridization,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0480,Cytopath smear prep & report,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0481,Electron microscopy,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0482,Direct immunofluorescence,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0483,Indirect immunofluorescence,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0484,Consult slides prep elsewher,Pathology,Per Unit,$20.19 ,OP,$20.19 ,$20.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0485,Consult inc prep of slides,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0486,Access of transep cytol samp,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0502,Other oral pathology procedu,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0600,Non-ionizing diag proc,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0601,Caries risk assess low risk,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0602,Caries risk assess mod risk,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0603,Caries risk assess high risk,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0604,Antigen test pub hlth pathog,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0605,Antibody test pub hlth path,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0701,Pano radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0702,2d cephal radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0703,2d oral/facial photo image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0704,3d photo image capture only,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0705,Extra oral post radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0706,Intraoral occlus radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0707,Intraoral periap radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0708,Intraoral bite radio image,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0709,Intraoral cmplt radio images,Dental,Per Unit,$31.95 ,OP,$31.95 ,$31.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D0999,Unspecified diagnostic proce,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1110,Dental prophylaxis adult,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1120,Dental prophylaxis child,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1206,Topical fluoride varnish,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1208,Topical app fluorid ex vrnsh,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1310,Nutri counsel-control caries,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1320,Tobacco counseling,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1321,Couns for high risk sub use,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1330,Oral hygiene instruction,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1351,Dental sealant per tooth,Dental,Per Unit,$24.50 ,OP,$24.50 ,$24.50 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1352,"Prev resin rest, perm tooth",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1353,Sealant repair per tooth,Dental,Per Unit,$24.50 ,OP,$24.50 ,$24.50 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1354,Int caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1355,Caries med app per tooth,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1510,Space maintainer fxd unilat,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1515,Fixed bilat space maintainer,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1516,"Fixed bilat space maint, max",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1517,"Fixed bilat space maint, man",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1520,Remove unilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1525,Remove bilat space maintain,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1526,"Remove bilat space main, max",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1527,"Remove bilat space main, man",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1550,Recement space maintainer,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1551,Recement space maint - max,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1552,Recement space maint - man,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1553,Recement unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1555,Remove fix space maintainer,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1556,Rem fixed unilat space maint,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1557,Remove fixed bilat maint max,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1558,Remove fixed bilat man,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1575,"Dist space maint, fixed unil",Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D1999,Unspecified preventive proc,Preventive Care,Per Unit,$98.77 ,OP,$98.77 ,$98.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2140,Amalgam one surface permanen,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2150,Amalgam two surfaces permane,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2160,Amalgam three surfaces perma,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2161,Amalgam 4 or > surfaces perm,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2330,Resin one surface-anterior,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2331,Resin two surfaces-anterior,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2332,Resin three surfaces-anterio,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2335,Resin 4/> surf or w incis an,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2390,Ant resin-based cmpst crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2391,Post 1 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2392,Post 2 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2393,Post 3 srfc resinbased cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2394,Post >=4srfc resinbase cmpst,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2410,Dental gold foil one surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2420,Dental gold foil two surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2430,Dental gold foil three surfa,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2510,Dental inlay metalic 1 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2520,Dental inlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2530,Dental inlay metl 3/more sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2542,Dental onlay metallic 2 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2543,Dental onlay metallic 3 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2544,Dental onlay metl 4/more sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2610,Inlay porcelain/ceramic 1 su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2620,Inlay porcelain/ceramic 2 su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2630,Dental onlay porc 3/more sur,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2642,Dental onlay porcelin 2 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2643,Dental onlay porcelin 3 surf,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2644,Dental onlay porc 4/more sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2650,Inlay composite/resin one su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2651,Inlay composite/resin two su,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2652,Dental inlay resin 3/mre sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2662,Dental onlay resin 2 surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2663,Dental onlay resin 3 surface,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2664,Dental onlay resin 4/mre sur,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2710,Crown resin-based indirect,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2712,Crown 3/4 resin-based compos,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2720,Crown resin w/ high noble me,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2721,Crown resin w/ base metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2722,Crown resin w/ noble metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2740,Crown porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2750,Crown porcelain w/ h noble m,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2751,Crown porcelain fused base m,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2752,Crown porcelain w/ noble met,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2753,Crown porc fused to titanium,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2780,Crown 3/4 cast hi noble met,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2781,Crown 3/4 cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2782,Crown 3/4 cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2790,Crown full cast high noble m,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2791,Crown full cast base metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2792,Crown full cast noble metal,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2794,Crown-titanium,Dental,Per Unit,"$1,115.94 ",OP,"$1,115.94 ","$1,115.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2799,Provisional crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2910,Recement inlay onlay or part,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2915,Recement cast or prefab post,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2920,Re-cement or re-bond crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2921,Reattach tooth fragment,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2928,Prefab porc/cer crown perm,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2929,Prefab porc/ceram crown pri,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2930,Prefab stnlss steel crwn pri,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2931,Prefab stnlss steel crown pe,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2932,Prefabricated resin crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2933,Prefab stainless steel crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2934,Prefab steel crown primary,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2941,Int therapeutic restoration,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2950,Core build-up incl any pins,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2951,Tooth pin retention,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2952,Post and core cast + crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2953,Each addtnl cast post,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2954,Prefab post/core + crown,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2955,Post removal,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2957,Each addtnl prefab post,Dental,Per Unit,"$1,014.48 ",OP,"$1,014.48 ","$1,014.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2960,Labial veneer resin direct,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2961,Labial veneer resin indirect,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2962,Labial veneer porc indirect,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2970,Temp crown (fractured tooth),Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2971,Add proc construct new crown,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2975,Coping,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2980,Crown repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2981,Inlay repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2982,Onlay repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2983,Veneer repair,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2990,Resin infiltration of lesion,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D2999,Dental unspec restorative pr,Dental,Per Unit,$936.64 ,OP,$936.64 ,$936.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3110,Pulp cap direct,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3120,Pulp cap indirect,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3220,Therapeutic pulpotomy,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3221,Gross pulpal debridement,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3222,Part pulp for apexogenesis,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3230,Pulpal therapy anterior prim,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3240,Pulpal therapy posterior pri,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3310,"End thxpy, anterior tooth",Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3320,"End thxpy, premolar tooth",Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3330,"End thxpy, molar tooth",Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3331,Non-surg tx root canal obs,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3332,Incomplete endodontic tx,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3333,Internal root repair,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3346,Retreat root canal anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3347,Retreat root canal premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3348,Retreat root canal molar,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3351,Apexification/recalc initial,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3352,Apexification/recalc interim,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3353,Apexification/recalc final,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3355,Pulpal regeneration initial,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3356,Pulpal regeneration interim,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3357,Pulpal regeneration complete,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3410,Apicoectomy - anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3421,Root surgery premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3425,Root surgery molar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3426,Root surgery ea add root,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3427,Periradicular surgery,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3428,Bone graft peri per tooth,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3429,Bone graft peri each addl,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3430,Retrograde filling,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3431,Biological materials,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3432,Guided tissue regeneration,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3450,Root amputation,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3460,Endodontic endosseous implan,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3470,Intentional replantation,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3471,Surg rep root res anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3472,Surg rep root res premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3473,Surg rep root res molar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3501,Surg exp root surf anterior,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3502,Surg exp root surf premolar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3503,Surg exp root surf molar,Dental,Per Unit,$134.32 ,OP,$134.32 ,$134.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3910,Isolation- tooth w rubb dam,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3920,Tooth splitting,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3950,Canal prep/fitting of dowel,Dental,Per Unit,$135.31 ,OP,$135.31 ,$135.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D3999,Endodontic procedure,Dental,Per Unit,$74.70 ,OP,$74.70 ,$74.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4210,Gingivectomy/plasty 4 or mor,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4211,Gingivectomy/plasty 1 to 3,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4212,Gingivectomy/plasty rest,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4230,Ana crown exp 4 or> per quad,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4231,Ana crown exp 1-3 per quad,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4240,Gingival flap proc w/ planin,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4241,Gngvl flap w rootplan 1-3 th,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4245,Apically positioned flap,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4249,Crown lengthen hard tissue,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4260,Osseous surgery 4 or more,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4261,Osseous surg 1 to 3 teeth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4263,Bone replce graft first site,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4264,Bone replce graft each add,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4265,Bio mtrls to aid soft/os reg,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4266,Guided tiss regen resorble,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4267,Guided tiss regen nonresorb,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4268,Surgical revision procedure,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4270,Pedicle soft tissue graft pr,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4273,Auto tissue graft 1st tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4274,Mesial/distal wedge proc,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4275,Non-auto graft 1st tooth,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4276,Con tissue w dble ped graft,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4277,Soft tissue graft firsttooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4278,Soft tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4283,Auto tissue graft addl tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4285,Non-auto graft addl tooth,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4320,Provision splnt intracoronal,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4321,Provisional splint extracoro,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4341,Periodontal scaling & root,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4342,Periodontal scaling 1-3teeth,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4346,Scaling gingiv inflammation,Dental,Per Unit,$596.23 ,OP,$596.23 ,$596.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4355,Full mouth debridement,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4381,Localized delivery antimicro,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4910,Periodontal maint procedures,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4920,Unscheduled dressing change,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4921,Gingival irrigation per quad,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D4999,Unspecified periodontal proc,Dental,Per Unit,$561.92 ,OP,$561.92 ,$561.92 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5110,Dentures complete maxillary,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5120,Dentures complete mandible,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5130,Dentures immediat maxillary,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5140,Dentures immediat mandible,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5211,Dentures maxill part resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5212,Dentures mand part resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5213,Dentures maxill part metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5214,Dentures mandibl part metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5221,Immed max part denture resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5222,Immed man part denture resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5223,Immed max part dent metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5224,Immed mand part dent metal,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5225,Maxillary part denture flex,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5226,Mandibular part denture flex,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5281,Removable partial denture,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5282,"Remove unil part denture,max",Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5283,"Remove unil part denture,man",Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5284,Rem unilat dent flex base,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5286,Rem unilat dent 1 pc resin,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5410,Dentures adjust cmplt maxil,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5411,Dentures adjust cmplt mand,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5421,Dentures adjust part maxill,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5422,Dentures adjust part mandbl,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5510,Dentur repr broken compl bas,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5511,Rep broke comp dent base man,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5512,Rep broke comp dent base max,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5520,Replace denture teeth complt,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5610,Dentures repair resin base,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5611,Rep resin part dent base man,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5612,Rep resin part dent base max,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5620,Rep part denture cast frame,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5621,Rep cast part frame man,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5622,Rep cast part frame max,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5630,Rep partial denture clasp,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5640,Replace part denture teeth,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5650,Add tooth to partial denture,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5660,Add clasp to partial denture,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5670,Replc tth&acrlc on mtl frmwk,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5671,Replc tth&acrlc mandibular,Dental,Per Unit,$136.23 ,OP,$136.23 ,$136.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5710,Dentures rebase cmplt maxil,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5711,Dentures rebase cmplt mand,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5720,Dentures rebase part maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5721,Dentures rebase part mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5730,Denture reln cmplt max dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5731,Denture reln cmplt mand dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5740,Denture reln part max dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5741,Denture reln part mand dir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5750,Denture reln cmplt max indir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5751,Denture reln cmplt mand ind,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5760,Denture reln part max indir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5761,Denture reln part mand indir,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5810,Denture interm cmplt maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5811,Denture interm cmplt mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5820,Denture interm part maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5821,Denture interm part mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5850,Denture tiss conditn maxill,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5851,Denture tiss condtin mandbl,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5862,Precision attachment,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5863,Overdenture complete max,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5864,Overdenture partial max,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5865,Overdenture complete mandib,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5866,Overdenture partial mandib,Dental,Per Unit,$162.24 ,OP,$162.24 ,$162.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5867,Replacement of precision att,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5875,Prosthesis modification,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5876,Add metal sub to acrylc dent,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5899,Removable prosthodontic proc,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5911,Facial moulage sectional,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5912,Facial moulage complete,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5913,Nasal prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5914,Auricular prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5915,Orbital prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5916,Ocular prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5919,Facial prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5922,Nasal septal prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5923,Ocular prosthesis interim,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5924,Cranial prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5925,Facial augmentation implant,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5926,Replacement nasal prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5927,Auricular replacement,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5928,Orbital replacement,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5929,Facial replacement,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5931,Surgical obturator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5932,Postsurgical obturator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5933,Refitting of obturator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5934,Mandibular flange prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5935,Mandibular denture prosth,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5936,Temp obturator prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5937,Trismus appliance,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5951,Feeding aid,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5952,Pediatric speech aid,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5953,Adult speech aid,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5954,Superimposed prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5955,Palatal lift prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5958,Intraoral con def inter plt,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5959,Intraoral con def mod palat,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5960,Modify speech aid prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5982,Surgical stent,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5983,Radiation applicator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5984,Radiation shield,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5985,Radiation cone locator,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5986,Fluoride applicator,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5987,Commissure splint,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5988,Surgical splint,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5991,Vesiculobullous disease carr,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5992,Adjust max prost appliance,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5993,Main/clean max prosthesis,Dental,Per Unit,$30.61 ,OP,$30.61 ,$30.61 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5994,Peridontal medicament,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5995,"Peri medicament w/seal, max",Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5996,"Peri medicament w/seal, mand",Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D5999,Maxillofacial prosthesis,Dental,Per Unit,$159.88 ,OP,$159.88 ,$159.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6010,Odontics endosteal implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6011,Second stage implant surgery,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6012,Endosteal implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6013,Surgical place mini implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6040,Odontics eposteal implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6050,Odontics transosteal implnt,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6051,Interim abutment,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6055,Implant connecting bar,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6056,Prefabricated abutment,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6057,Custom abutment,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6058,Abutment supported crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6059,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6060,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6061,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6062,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6063,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6064,Abutment supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6065,Implant supported crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6066,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6067,Implant supported mtl crown,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6068,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6069,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6070,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6071,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6072,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6073,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6074,Abutment supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6075,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6076,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6077,Implant supported retainer,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6080,Implant maintenance,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6081,"Scale & debride, single imp",Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6082,Imp crown porc to base alloy,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6083,Imp crown porc to noble allo,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6084,Imp crown porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6085,Provisional implant crown,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6086,Imp crown base alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6087,Implant crown noble alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6088,Imp crown titanium alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6090,Repair implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6091,Repl semi/precision attach,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6092,Recement supp crown,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6093,Recement supp part denture,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6094,Abut support crown titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6095,Odontics repr abutment,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6096,Remove broken imp ret screw,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6097,Abut crown porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6098,Imp retain porc to base allo,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6099,Imp retainer for fpd,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6100,Removal of implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6101,Debridement of a periimplant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6102,Debridement & contouring,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6103,Bone graft repair perimplant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6104,Bone graft time of implant,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6110,Implnt/abut remov dent max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6111,Implnt/abut remov dent mand,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6112,Imp/abut rem dent part max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6113,Imp/abut rem dent part mand,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6114,Implnt/abut fixed dent max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6115,Implnt/abut fixed dent mand,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6116,Imp/abut fixed dent part max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6117,Imp/abut fixed dent part man,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6118,Imp/abut int fixed dent man,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6119,Int/abut int fixed dent max,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6120,Imp retain porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6121,Retain metal fpd base alloys,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6122,Retain metal fpd noble alloy,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6123,Retain metal fpd titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6190,Radio/surgical implant index,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6191,Semi precision abutment,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6192,Semi precision attachment,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6194,Abut support retainer titani,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6195,Abut retain porc to titanium,Dental,Per Unit,$757.63 ,OP,$757.63 ,$757.63 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6199,Implant procedure,Dental,Per Unit,$688.76 ,OP,$688.76 ,$688.76 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6205,Pontic-indirect resin based,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6210,Prosthodont high noble metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6211,Bridge base metal cast,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6212,Bridge noble metal cast,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6214,Pontic titanium,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6240,Bridge porcelain high noble,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6241,Bridge porcelain base metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6242,Bridge porcelain nobel metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6243,Pontic porcelain to titanium,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6245,Bridge porcelain/ceramic,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6250,Bridge resin w/high noble,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6251,Bridge resin base metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6252,Bridge resin w/noble metal,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6253,Provisional pontic,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6545,Dental retainr cast metl,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6548,Porcelain/ceramic retainer,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6549,Resin retainer,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6600,Porcelain/ceramic inlay 2srf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6601,Porc/ceram inlay >= 3 surfac,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6602,Cst hgh nble mtl inlay 2 srf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6603,Cst hgh nble mtl inlay >=3sr,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6604,Cst bse mtl inlay 2 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6605,Cst bse mtl inlay >= 3 surfa,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6606,Cast noble metal inlay 2 sur,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6607,Cst noble mtl inlay >=3 surf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6608,Onlay porc/crmc 2 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6609,Onlay porc/crmc >=3 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6610,Onlay cst hgh nbl mtl 2 srfc,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6611,Onlay cst hgh nbl mtl >=3srf,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6612,Onlay cst base mtl 2 surface,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6613,Onlay cst base mtl >=3 surfa,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6614,Onlay cst nbl mtl 2 surfaces,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6615,Onlay cst nbl mtl >=3 surfac,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6624,Inlay titanium,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6634,Onlay titanium,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6710,Crown-indirect resin based,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6720,Retain crown resin w hi nble,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6721,Crown resin w/base metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6722,Crown resin w/noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6740,Crown porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6750,Crown porcelain high noble,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6751,Crown porcelain base metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6752,Crown porcelain noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6753,Retain crown porc to titaniu,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6780,Crown 3/4 high noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6781,Crown 3/4 cast based metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6782,Crown 3/4 cast noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6783,Crown 3/4 porcelain/ceramic,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6784,Retainer crown 3/4 titanium,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6790,Crown full high noble metal,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6791,Crown full base metal cast,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6792,Crown full noble metal cast,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6793,Provisional retainer crown,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6794,Crown titanium,Dental,Per Unit,$251.59 ,OP,$251.59 ,$251.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6920,Dental connector bar,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6930,Recement/bond part denture,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6940,Stress breaker,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6950,Precision attachment,Dental,Per Unit,$54.36 ,OP,$54.36 ,$54.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6980,Fixed partial repair,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6985,Pediatric partial denture fx,Dental,Per Unit,$203.37 ,OP,$203.37 ,$203.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D6999,Fixed prosthodontic proc,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7111,Extraction coronal remnants,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7140,Extraction erupted tooth/exr,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7210,Rem imp tooth w mucoper flp,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7220,Impact tooth remov soft tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7230,Impact tooth remov part bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7240,Impact tooth remov comp bony,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7241,Impact tooth rem bony w/comp,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7250,Tooth root removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7251,Coronectomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7260,Oral antral fistula closure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7261,Primary closure sinus perf,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7270,Tooth reimplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7272,Tooth transplantation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7280,Exposure of unerupted tooth,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7282,Mobilize erupted/malpos toot,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7283,Place device impacted tooth,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7285,Biopsy of oral tissue hard,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7286,Biopsy of oral tissue soft,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7287,Exfoliative cytolog collect,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7288,Brush biopsy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7290,Repositioning of teeth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7291,Transseptal fiberotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7292,Screw retained plate,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7293,Temp anchorage dev w flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7294,Temp anchorage dev w/o flap,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7295,"Bone harvest,auto graft proc",Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7296,"Corticotomy, 1-3 teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7297,"Corticotomy, 4 or more teeth",Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7310,Alveoplasty w/ extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7311,Alveoloplasty w/extract 1-3,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7320,Alveoplasty w/o extraction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7321,Alveoloplasty not w/extracts,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7340,Vestibuloplasty ridge extens,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7350,Vestibuloplasty exten graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7410,Rad exc lesion up to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7411,Excision benign lesion>1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7412,Excision benign lesion compl,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7413,Excision malig lesion<=1.25c,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7414,Excision malig lesion>1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7415,Excision malig les complicat,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7440,Malig tumor exc to 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7441,Malig tumor > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7450,Rem odontogen cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7451,Rem odontogen cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7460,Rem nonodonto cyst to 1.25cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7461,Rem nonodonto cyst > 1.25 cm,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7465,Lesion destruction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7471,Rem exostosis any site,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7472,Removal of torus palatinus,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7473,Remove torus mandibularis,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7485,Surg reduct osseoustuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7490,Maxilla or mandible resectio,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7510,I&d absc intraoral soft tiss,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7511,Incision/drain abscess intra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7520,I&d abscess extraoral,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7521,Incision/drain abscess extra,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7530,Removal fb skin/areolar tiss,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7540,Removal of fb reaction,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7550,Removal of sloughed off bone,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7560,Maxillary sinusotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7610,Maxilla open reduct simple,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7620,Clsd reduct simpl maxilla fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7630,Open red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7640,Clsd red simpl mandible fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7650,Open red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7660,Clsd red simp malar/zygom fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7670,Closd rductn splint alveolus,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7671,Alveolus open reduction,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7680,Reduct simple facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7710,Maxilla open reduct compound,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7720,Clsd reduct compd maxilla fx,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7730,Open reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7740,Clsd reduct compd mandble fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7750,Open red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7760,Clsd red comp malar/zygma fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7770,Open reduc compd alveolus fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7771,Alveolus clsd reduc stblz te,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7780,Reduct compnd facial bone fx,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7810,Tmj open reduct-dislocation,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7820,Closed tmp manipulation,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7830,Tmj manipulation under anest,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7840,Removal of tmj condyle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7850,Tmj meniscectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7852,Tmj repair of joint disc,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7854,Tmj excisn of joint membrane,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7856,Tmj cutting of a muscle,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7858,Tmj reconstruction,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7860,Tmj cutting into joint,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7865,Tmj reshaping components,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7870,Tmj aspiration joint fluid,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7871,Lysis + lavage w catheters,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7872,Tmj diagnostic arthroscopy,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7873,Tmj arthroscopy lysis adhesn,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7874,Tmj arthroscopy disc reposit,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7875,Tmj arthroscopy synovectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7876,Tmj arthroscopy discectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7877,Tmj arthroscopy debridement,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7880,Occlusal orthotic appliance,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7881,Occ orthotic device adjust,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7899,Tmj unspecified therapy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7910,Dent sutur recent wnd to 5cm,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7911,Dental suture wound to 5 cm,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7912,Suture complicate wnd > 5 cm,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7920,Dental skin graft,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7921,Collect & appl blood product,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7922,Place intra-socket bio dress,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7940,Reshaping bone orthognathic,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7941,Bone cutting ramus closed,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7943,Cutting ramus open w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7944,Bone cutting segmented,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7945,Bone cutting body mandible,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7946,Reconstruction maxilla total,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7947,Reconstruct maxilla segment,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7948,Reconstruct midface no graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7949,Reconstruct midface w/graft,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7950,Mandible graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7951,Sinus aug w bone or bone sub,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7952,Sinus augmentation vertical,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7953,Bone replacement graft,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7955,Repair maxillofacial defects,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7960,Frenulectomy/frenectomy,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7961,Buccal/labial frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7962,Lingual frenectomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7963,Frenuloplasty,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7970,Excision hyperplastic tissue,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7971,Excision pericoronal gingiva,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7972,Surg redct fibrous tuberosit,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7979,Non-surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7980,Surgical sialolithotomy,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7981,Excision of salivary gland,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7982,Sialodochoplasty,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7983,Closure of salivary fistula,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7990,Emergency tracheotomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7991,Dental coronoidectomy,Oral and Maxillofacial Surgery,Per Unit,$451.22 ,OP,$451.22 ,$451.22 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7993,Surg place craniofacial impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7994,Surg place zygomatic impl,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7995,Synthetic graft facial bones,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7996,Implant mandible for augment,Oral and Maxillofacial Surgery,Per Unit,$410.20 ,OP,$410.20 ,$410.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7997,Appliance removal,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7998,Intraoral place of fix dev,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D7999,Oral surgery procedure,Oral and Maxillofacial Surgery,Per Unit,$394.52 ,OP,$394.52 ,$394.52 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8010,Limited dental tx primary,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8020,Limited dental tx transition,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8030,Limited dental tx adolescent,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8040,Limited dental tx adult,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8050,Intercep dental tx primary,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8060,Intercep dental tx transitn,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8070,Compre dental tx transition,Dental,Per Unit,$195.04 ,OP,$195.04 ,$195.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8080,Compre dental tx adolescent,Dental,Per Unit,$195.04 ,OP,$195.04 ,$195.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8090,Compre dental tx adult,Dental,Per Unit,$195.04 ,OP,$195.04 ,$195.04 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8210,Orthodontic rem appliance tx,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8220,Fixed appliance therapy habt,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8660,Preorthodontic tx visit,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8670,Periodic orthodontc tx visit,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8680,Orthodontic retention,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8681,Removable retainer adjust,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8690,Orthodontic treatment,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8691,Repair ortho appliance,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8692,Replacement retainer,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8693,Rebond/recement retainers,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8694,Repair fixed retainers,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8695,Remove fixed ortho appliance,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8696,Rep of ortho appliance max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8697,Rep of ortho appliance man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8698,Recement fixed retainer max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8699,Recement fixed retainer man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8701,Repair fixed retainer max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8702,Repair of fixed retainer man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8703,Replace broken retainer max,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8704,Replace broken retainer man,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D8999,Orthodontic procedure,Dental,Per Unit,$177.32 ,OP,$177.32 ,$177.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9110,Tx dental pain minor proc,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9120,Fix partial denture section,Dental,Per Unit,$110.21 ,OP,$110.21 ,$110.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9130,Temporomandibular joint dysf,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9210,Dent anesthesia w/o surgery,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9211,Regional block anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9212,Trigeminal block anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9215,Local anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9219,Eval mod/deep sed/gen anest,Dental,Per Unit,$130.37 ,OP,$130.37 ,$130.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9220,General anesthesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9221,General anesthesia ea ad 15m,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9222,"Deep anest, 1st 15 min",Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9223,General anesth ea addl 15 mi,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9230,Analgesia,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9239,"Iv mod sedation, 1st 15 min",Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9241,Intravenous sedation,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9242,Iv sedation ea ad 15 m,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9243,Iv sedation ea addl 15m,Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9248,Sedation (non-iv),Dental,Per Unit,$24.43 ,OP,$24.43 ,$24.43 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9310,Dental consultation,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9311,Consult w/med hlth care prof,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9410,Dental house call,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9420,Hospital/asc call,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9430,Office visit during hours,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9440,Office visit after hours,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9450,Case presentation tx plan,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9610,Dent therapeutic drug inject,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9612,Thera par drugs 2 or > admin,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9613,Infiltration thera drug,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9630,Drugs/meds disp for home use,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9910,Dent appl desensitizing med,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9911,Appl desensitizing resin,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9920,Behavior management,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9930,Treatment of complications,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9931,Clean/inspect rem appliance,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9932,Clean & inspect rem dent max,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9933,Clean & inspect rem dent man,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9934,Clean rem part denture max,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9935,Clean rem part denture mand,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9940,Dental occlusal guard,Dental,Per Unit,$156.21 ,OP,$156.21 ,$156.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9941,Fabrication athletic guard,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9942,Repair/reline occlusal guard,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9943,Occlusal guard adjustment,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9944,"Occ guard, hard, full arch",Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9945,"Occ guard, soft, full arch",Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9946,"Occ guard, hard, part arch",Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9950,Occlusion analysis,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9951,Limited occlusal adjustment,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9952,Complete occlusal adjustment,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9970,Enamel microabrasion,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9971,Odontoplasty per tooth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9972,Extrnl bleaching per arch,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9973,Extrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9974,Intrnl bleaching per tooth,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9975,External bleaching home app,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9991,"Case mgmt, appt barriers",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9992,"Case mgmt, care coordination",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9993,"Case mgmt, interviewing",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9994,"Case mgmt, pt education",Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9995,Teledentistry real-time,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9996,Teledentistry dent review,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9997,Dent case mgmt special needs,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,D9999,Adjunctive procedure,Dental,Per Unit,$136.51 ,OP,$136.51 ,$136.51 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0008,Admin influenza virus vac,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0009,Admin pneumococcal vaccine,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0010,Admin hepatitis b vaccine,Ancillary Services,Per Unit,$23.26 ,OP,$23.26 ,$23.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0027,Semen analysis,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0068,Adm iv infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0069,Adm sq infusion drug in home,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0070,Adm of chemo drug in home,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0071,Comm svcs by rhc/fqhc 5 min,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0076,Care manag h vst new pt 20 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0077,Care manag h vst new pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0078,Care manag h vst new pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0079,Care manag h vst new pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0080,Care manag h vst new pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0081,Care man h v ext pt 20 mi,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0082,Care man h v ext pt 30 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0083,Care man h v ext pt 45 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0084,Care man h v ext pt 60 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0085,Care man h v ext pt 75 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0086,Care man home care plan 30 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0087,Care man home care plan 60 m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0088,Adm iv drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0089,Adm subq drug 1st home visit,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0090,Adm iv chemo 1st home visit,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0103,Psa screening,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0104,Ca screen;flexi sigmoidscope,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0105,Colorectal scrn; hi risk ind,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0108,Diab manage trn per indiv,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0109,Diab manage trn ind/group,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0117,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0118,Glaucoma scrn hgh risk direc,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0121,Colon ca scrn not hi rsk ind,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0122,Colon ca scrn; barium enema,Diagnostic Radiology,Per Unit,$31.74 ,OP,$31.74 ,$31.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0123,Screen cerv/vag thin layer,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0124,Screen c/v thin layer by md,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0127,Trim nail(s),General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0128,Corf skilled nursing service,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0130,Single energy x-ray study,Diagnostic Radiology,Per Unit,$50.13 ,OP,$50.13 ,$50.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0141,"Scr c/v cyto,autosys and md",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0143,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0144,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0145,"Scr c/v cyto,thinlayer,rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0147,"Scr c/v cyto, automated sys",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0148,"Scr c/v cyto, autosys, rescr",Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0151,"Hhcp-serv of pt,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0152,"Hhcp-serv of ot,ea 15 min",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0153,"Hhcp-svs of s/l path,ea 15mn",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0155,"Hhcp-svs of csw,ea 15 min",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0157,Hhc pt assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0158,Hhc ot assistant ea 15,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0159,Hhc pt maint ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0160,Hhc occup therapy ea 15,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0161,Hhc slp ea 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0162,"Hhc rn e&m plan svs, 15 min",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0166,"Extrnl counterpulse, per tx",Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0175,"Opps service,sched team conf",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0176,Opps/php;activity therapy,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0177,Opps/php; train & educ serv,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0179,Md recertification hha pt,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0180,Md certification hha patient,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0181,Home health care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0182,Hospice care supervision,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0186,"Dstry eye lesn,fdr vssl tech",Ophthalmology Surgery,Per Unit,$312.24 ,OP,$312.24 ,$312.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0202,Scr mammo bi incl cad,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0204,Dx mammo incl cad bi,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0206,Dx mammo incl cad uni,Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0219,Pet img wholbod melano nonco,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0235,Pet not otherwise specified,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0237,Therapeutic procd strg endur,Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0238,"Oth resp proc, indiv",Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0239,"Oth resp proc, group",Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0248,Demonstrate use home inr mon,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0252,Pet imaging initial dx,Diagnostic Radiology,Per Unit,$697.72 ,OP,$697.72 ,$697.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0255,Current percep threshold tst,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0257,Unsched dialysis esrd pt hos,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0270,Mnt subs tx for change dx,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0271,Group mnt 2 or more 30 mins,Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0278,"Iliac art angio,cardiac cath",Interventional Radiology,Per Unit,"$1,525.89 ",OP,"$1,525.89 ","$1,525.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0279,"Tomosynthesis, mammo",Diagnostic Radiology,Per Unit,$39.40 ,OP,$39.40 ,$39.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0283,Elec stim other than wound,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0289,"Arthro, loose body + chondro",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0293,"Non-cov surg proc,clin trial",Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0297,Ldct for lung ca screen,Diagnostic Radiology,Per Unit,$162.95 ,OP,$162.95 ,$162.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0306,Cbc/diffwbc w/o platelet,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0307,Cbc without platelet,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0328,Fecal blood scrn immunoassay,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0339,"Robot lin-radsurg com, first",Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0340,Robt lin-radsurg fractx 2-5,Therapeutic Radiology,Per Unit,"$2,592.65 ",OP,"$2,592.65 ","$2,592.65 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0365,Vessel mapping hemo access,Diagnostic Radiology,Per Unit,$114.16 ,OP,$114.16 ,$114.16 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0378,Hospital observation per hr,Ancillary Services,Per Unit,$651.20 ,OP,$651.20 ,$651.20 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0389,Ultrasound exam aaa screen,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0396,Alcohol/subs interv 15-30mn,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0397,Alcohol/subs interv >30 min,Behavioral Health,Per Unit,$84.55 ,OP,$84.55 ,$84.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0403,Ekg for initial prevent exam,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0404,Ekg tracing for initial prev,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0405,Ekg interpret & report preve,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0409,Corf related serv 15 mins ea,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0410,Grp psych partial hosp 45-50,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0411,Inter active grp psych parti,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0412,Open tx iliac spine uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0413,Pelvic ring fracture uni/bil,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0414,Pelvic ring fx treat int fix,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0415,Open tx post pelvic fxcture,Orthopedic Surgery,Per Unit,"$2,555.93 ",OP,"$2,555.93 ","$2,555.93 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0420,Ed svc ckd ind per session,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0421,Ed svc ckd grp per session,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0422,Intens cardiac rehab w/exerc,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0423,Intens cardiac rehab no exer,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0424,Pulmonary rehab w exer,Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0431,Drug screen multiple class,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0432,Eia hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0433,Elisa hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0434,Drug screen multi drug class,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0435,Oral hiv-1/hiv-2 screen,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0436,Tobacco-use counsel 3-10 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0437,Tobacco-use counsel>10min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0442,Annual alcohol screen 15 min,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0443,Brief alcohol misuse counsel,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0444,Depression screen annual,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0445,High inten beh couns std 30m,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0446,Intens behave ther cardio dx,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0447,Behavior counsel obesity 15m,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0448,Place perm pacing cardiovert,Interventional Cardiology,Per Unit,"$13,158.48 ",OP,"$13,158.48 ","$13,158.48 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0451,Devlopment test interpt&rep,Behavioral Health,Per Unit,$458.21 ,OP,$458.21 ,$458.21 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0452,Molecular pathology interpr,Pathology,Per Unit,$18.36 ,OP,$18.36 ,$18.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0459,Telehealth inpt pharm mgmt,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0464,"Colorec CA scr, sto bas DNA",Laboratory,Per Unit,$210.68 ,OP,$210.68 ,$210.68 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0472,Hep c screen high risk/other,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0473,Group behave couns 2-10,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0475,Hiv combination assay,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0476,Hpv combo assay ca screen,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0477,Drug test presump optical,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0478,Drug test presump opt inst,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0479,Drug test presump not opt,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0480,Drug test def 1-7 classes,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0491,Dialysis acu kidney no esrd,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0492,Md/oth eval acut kid no esrd,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0495,Rn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0496,Lpn care train/edu in hh,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0498,Chemo extend iv infus w/pump,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0499,Hepb screen high risk indiv,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0500,Mod sedat endo service >5yrs,Anesthesia,Per Unit,$13.45 ,OP,$13.45 ,$13.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0502,"Init psych care manag, 70min",Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0503,"Subseq psych care man,60mi",Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0504,Init/sub psych care add 30 m,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0506,Comp asses care plan ccm svc,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0507,Care manage serv minimum 20,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0511,Ccm/bhi by rhc/fqhc 20min mo,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0512,Cocm by rhc/fqhc 60 min mo,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0515,Cognitive skills development,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0516,"Insert drug del implant, >=4",General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0517,Remove drug implant,General Surgery,Per Unit,$171.35 ,OP,$171.35 ,$171.35 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0518,Remove w insert drug implant,General Surgery,Per Unit,$597.65 ,OP,$597.65 ,$597.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G0659,Drug test def simple all cl,Laboratory,Per Unit,$17.30 ,OP,$17.30 ,$17.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2000,Blinded conv. tx mdd clin tr,Behavioral Health,Per Unit,$276.44 ,OP,$276.44 ,$276.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2010,Remot image submit by pt,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2011,Alcohol/sub misuse assess,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2012,Brief check in by md/qhp,Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2014,Post-d/c care plan overs 30m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2015,Post-d/c care plan overs 60m,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2058,Ccm add 20min,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2064,Md mang high risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2065,Clin mang h risk dx 30,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2066,Inter devc remote 30d,Ancillary Services,Per Unit,$24.11 ,OP,$24.11 ,$24.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2082,Visit esketamine 56m or less,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2083,"Visit esketamine, > 56m",Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2168,Svs by pt in home health,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2169,Svs by ot in home health,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2213,Initiat med assist tx in er,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2214,Init/sub psych care m 1st 30,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2250,"Remot img sub by pt, non e/m",Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2251,"Brief chkin, 5-10, non-e/m",Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G2252,"Brief chkin by md/qhp, 11-20",Ancillary Services,Per Unit,$26.19 ,OP,$26.19 ,$26.19 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G3001,"Admin + supply, tositumomab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6001,Echo guidance radiotherapy,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6002,Stereoscopic x-ray guidance,Interventional Radiology,Per Unit,$180.85 ,OP,$180.85 ,$180.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6003,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6004,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6005,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6006,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6007,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6008,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6009,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6010,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6011,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6012,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6013,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6014,Radiation treatment delivery,Therapeutic Radiology,Per Unit,$469.79 ,OP,$469.79 ,$469.79 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6015,Radiation tx delivery imrt,Therapeutic Radiology,Per Unit,$279.80 ,OP,$279.80 ,$279.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6016,Delivery comp imrt,Therapeutic Radiology,Per Unit,$434.17 ,OP,$434.17 ,$434.17 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6018,Ileoscopy w/stent,Gastroenterology,Per Unit,"$1,302.71 ",OP,"$1,302.71 ","$1,302.71 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6019,Colonoscopy lesion removal,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6020,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6021,Unlisted px small intestine,General Surgery,Per Unit,$960.01 ,OP,$960.01 ,$960.01 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6022,Sigmoidoscopy w/ablate tumr,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6023,Sigmoidoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6024,Lesion removal colonoscopy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6025,Colonoscopy w/stent,Gastroenterology,Per Unit,$476.14 ,OP,$476.14 ,$476.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6027,Anoscopy hra w/spec collect,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6028,Anoscopy hra w/biopsy,Gastroenterology,Per Unit,$427.85 ,OP,$427.85 ,$427.85 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6030,Assay of amitriptyline,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6031,Assay of benzodiazepines,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6032,Assay of desipramine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6034,Assay of doxepin,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6035,Assay of gold,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6036,Assay of Imipramine,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6037,Assay of nortiptyline,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6038,Assay of salicylate,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6039,Assay of acetaminophen,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6040,Assay of ethanol,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6041,Assay of urine alkaloids,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6042,Assay of amphetamines,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6043,Assay of barbiturates,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6044,Assay of cocaine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6045,Assay of dihydrocodeinone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6046,Assay of dihydromorphinone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6047,Assay of dihydrotestosterone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6048,Assay of dimethadione,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6049,Assay of Epiandrosterone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6050,Assay of Ethchlorvynol,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6051,Assay of flurazepam,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6052,Assay of meprobamate,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6053,Assay of methadone,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6054,Assay of methsuximide,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6055,Assay of nicotine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6056,Assay of opiates,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6057,Assay of phenothiazine,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G6058,Drug confirmation,Laboratory,Per Unit,$7.84 ,OP,$7.84 ,$7.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9012,Other specified case mgmt,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9016,Demo-smoking cessation coun,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9020,Rimantadine hcl 100mg oral,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9034,"Zanamivir, inh pwdr, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9035,"Oseltamivir phosp, brand",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9143,Warfarin respon genetic test,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9147,Outpt iv insulin tx any mea,General Medicine,Per Unit,$278.91 ,OP,$278.91 ,$278.91 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9157,Transesoph doppl cardiac mon,Cardiology,Per Unit,$276.65 ,OP,$276.65 ,$276.65 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9187,Bpci home visit,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9477,Care coord at hospice,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9686,Nursing facility conference,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9873,1 em core session,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9874,4 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9875,9 em core sessions,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9876,2 em core ms mo 7-9 no wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9877,2 em core ms mo 10-12 no wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9878,2 em core ms mo 7-9 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9879,2 em core ms mo 10-12 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9880,Em 5 percent wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9881,Em 9 percent wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9882,2 em ongoing ms mo 13-15 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9883,2 em ongoing ms mo 16-18 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9884,2 em ongoing ms mo 19-21 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9885,2 em ongoing ms mo 22-24 wl,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9890,Em bridge payment,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,G9987,Bpci advanced in home visit,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0001,Alcohol and/or drug assess,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0002,Alcohol and/or drug screenin,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0003,Alcohol and/or drug screenin,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0004,Alcohol and/or drug services,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0005,Alcohol and/or drug services,Behavioral Health,Per Unit,$119.88 ,OP,$119.88 ,$119.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0006,Alcohol and/or drug services,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0007,Alcohol and/or drug services,Behavioral Health,Per Unit,$135.70 ,OP,$135.70 ,$135.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0014,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0015,Alcohol and/or drug services,Behavioral Health,Per Unit,$339.88 ,OP,$339.88 ,$339.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0020,Alcohol and/or drug services,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0022,Alcohol and/or drug interven,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0031,Mh health assess by non-md,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0032,Mh svc plan dev by non-md,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0033,Oral med adm direct observe,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0034,Med trng & support per 15min,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0035,Mh partial hosp tx under 24h,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0037,Comm psy sup tx pgm per diem,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0046,"Mental health service, nos",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0047,Alcohol/drug abuse svc nos,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0049,Alcohol/drug screening,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H0050,Alcohol/drug service 15 min,Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H1002,Carecoordination prenatal,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H1003,Prenatal at risk education,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H1011,Family assessment,Behavioral Health,Per Unit,$156.88 ,OP,$156.88 ,$156.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2000,Comp multidisipln evaluation,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2001,Rehabilitation program 1/2 d,Behavioral Health,Per Unit,$166.94 ,OP,$166.94 ,$166.94 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2010,Comprehensive med svc 15 min,Behavioral Health,Per Unit,$80.13 ,OP,$80.13 ,$80.13 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2011,"Crisis interven svc, 15 min",Behavioral Health,Per Unit,$135.70 ,OP,$135.70 ,$135.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2012,"Behav hlth day treat, per hr",Behavioral Health,Per Unit,$276.34 ,OP,$276.34 ,$276.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2014,"Skills train and dev, 15 min",Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2017,"Psysoc rehab svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2018,"Psysoc rehab svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2019,"Ther behav svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2020,"Ther behav svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2027,"Psychoed svc, per 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2028,"Sex offend tx svc, 15 min",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2029,"Sex offend tx svc, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2032,"Activity therapy, per 15 min",Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2033,Multisys ther/juvenile 15min,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2035,"A/d tx program, per hour",Behavioral Health,Per Unit,$84.40 ,OP,$84.40 ,$84.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,H2036,"A/d tx program, per diem",Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0121,"Inj., omadacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0122,"Inj., eravacycline, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0129,Abatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0130,Abciximab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0135,Adalimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0178,Aflibercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0179,"Inj, brolucizumab-dbll, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0180,Agalsidase beta injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0185,"Inj., aprepitant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0202,"Injection, alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0205,Alglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0207,Amifostine,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0210,Methyldopate hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0215,Alefacept,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0220,Alglucosidase alfa injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0221,Lumizyme injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0222,"Inj., patisiran, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0223,Inj givosiran 0.5 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0256,Alpha 1 proteinase inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0257,Glassia injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0287,Amphotericin b lipid complex,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0288,Ampho b cholesteryl sulfate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0289,Amphotericin b liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0291,"Inj., plazomicin, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0348,Anidulafungin injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0350,Injection anistreplase 30 u,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0364,Apomorphine hydrochloride,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0365,"Aprotonin, 10,000 kiu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0401,Inj aripiprazole ext rel 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0475,Baclofen 10 mg injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0480,Basiliximab,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0485,Belatacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0490,Belimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0517,"Inj., benralizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0558,Peng benzathine/procaine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0561,Penicillin g benzathine inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0565,"Inj, bezlotoxumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0567,"Inj., cerliponase alfa 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0570,Buprenorphine implant 74.2mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0583,Bivalirudin,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0584,"Injection, burosumab-twza 1m",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0585,"Injection,onabotulinumtoxina",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0586,Abobotulinumtoxina,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0587,"Inj, rimabotulinumtoxinb",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0588,Incobotulinumtoxin a,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0591,"Inj deoxycholic acid, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0593,"Inj., lanadelumab-flyo, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0594,Busulfan injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0596,"Injection, ruconest",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0597,"C-1 esterase, berinert",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0598,"C-1 esterase, cinryze",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0599,"Inj., haegarda 10 units",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0600,Edetate calcium disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0604,"Cinacalcet, esrd on dialysis",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0606,"Inj, etelcalcetide, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0630,Calcitonin salmon injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0637,Caspofungin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0638,Canakinumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0641,Inj levoleucovorin nos 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0642,"Injection, khapzory, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0691,Inj lefamulin 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0693,"Inj., cefiderocol, 5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0695,Inj ceftolozane tazobactam,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0712,Ceftaroline fosamil inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0714,Ceftazidime and avibactam,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0716,Centruroides immune f(ab),Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0717,Certolizumab pegol inj 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0740,Cidofovir injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0742,Inj imip 4 cilas 4 releb 2mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0775,"Collagenase, clost hist inj",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0791,Inj crizanlizumab-tmca 5mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0795,Corticorelin ovine triflutal,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0800,Corticotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0833,Cosyntropin injection nos,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0840,Crotalidae poly immune fab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0841,Inj crotalidae im f(ab')2 eq,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0850,Cytomegalovirus imm iv /vial,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0875,"Injection, dalbavancin",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0878,Daptomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0881,"Darbepoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0882,"Darbepoetin alfa, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0883,Argatroban nonesrd use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0884,Argatroban esrd dialysis 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0885,"Epoetin alfa, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0886,Epoetin alfa 1000 units esrd,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0890,Peginesatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0894,Decitabine injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0896,Inj luspatercept-aamt 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J0897,Denosumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1095,"Injection, dexamethasone 9%",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1096,Dexametha opth insert 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1097,Phenylep ketorolac opth soln,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1162,Digoxin immune fab (ovine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1190,Dexrazoxane hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1201,Inj. cetirizine hcl 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1205,Chlorothiazide sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1212,Dimethyl sulfoxide 50% 50 ml,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1267,Doripenem injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1290,Ecallantide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1300,Eculizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1301,"Injection, edaravone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1303,"Inj., ravulizumab-cwvz 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1322,"Elosulfase alfa, injection",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1327,Eptifibatide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1410,Inj estrogen conjugate 25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1428,"Inj, eteplirsen, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1429,Inj golodirsen 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1430,Ethanolamine oleate 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1436,Etidronate disodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1437,Inj. fe derisomaltose 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1438,Etanercept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1439,Inj ferric carboxymaltos 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1442,Inj filgrastim excl biosimil,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1446,"Inj, tbo-filgrastim, 5 mcg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1447,Inj tbo filgrastim 1 microg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1451,"Fomepizole, 15 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1452,Intraocular fomivirsen na,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1453,Fosaprepitant injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1454,"Inj fosnetupitant, palonoset",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1455,Foscarnet sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1457,Gallium nitrate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1458,Galsulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1459,Inj ivig privigen 500 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1460,Gamma globulin 1 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1555,"Inj cuvitru, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1556,"Inj, imm glob bivigam, 500mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1557,Gammaplex injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1558,"Inj. xembify, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1559,Hizentra injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1560,Gamma globulin > 10 cc inj,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1561,Gamunex-c/gammaked,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1562,"Vivaglobin, inj",Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1566,"Immune globulin, powder",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1568,Octagam injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1569,Gammagard liquid injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1570,Ganciclovir sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1571,Hepagam b im injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1572,Flebogamma injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1573,"Hepagam b intravenous, inj",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1575,Hyqvia 100mg immuneglobulin,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1595,Injection glatiramer acetate,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1599,"Ivig non-lyophilized, nos",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1602,Golimumab for iv use 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1610,Glucagon hydrochloride/1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1628,"Inj., guselkumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1632,"Inj., brexanolone, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1640,"Hemin, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1670,Tetanus immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1675,Histrelin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1738,Inj. meloxicam 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1740,Ibandronate sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1742,Ibutilide fumarate injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1743,Idursulfase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1744,Icatibant injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1745,Infliximab not biosimil 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1746,"Inj., ibalizumab-uiyk, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1750,Inj iron dextran,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1756,Iron sucrose injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1786,Imuglucerase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1823,"Inj. inebilizumab-cdon, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1826,Interferon beta-1a inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1830,Interferon beta-1b / .25 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1833,"Injection, isavuconazonium",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1930,Lanreotide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1931,Laronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1942,Aripiprazole lauroxil 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1943,"Inj., aristada initio, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1944,Aripirazole lauroxil 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1945,Lepirudin,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J1950,Leuprolide acetate /3.75 mg,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2062,Loxapine for inhalation 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2170,Mecasermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2182,"Injection, mepolizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2186,"Inj., meropenem, vaborbactam",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2248,Micafungin sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2278,Ziconotide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2315,"Naltrexone, depot form",Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2323,Natalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2325,Nesiritide injection,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2326,"Inj, nusinersen, 0.1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2350,"Injection, ocrelizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2353,"Octreotide injection, depot",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2355,Oprelvekin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2357,Omalizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2407,"Injection, oritavancin",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2425,Palifermin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2426,Paliperidone palmitate inj,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2469,Palonosetron hcl,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2502,"Inj, pasireotide long acting",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2503,Pegaptanib sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2504,"Pegademase bovine, 25 iu",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2505,"Injection, pegfilgrastim 6mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2507,Pegloticase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2513,Pentastarch 10% solution,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2515,Pentobarbital sodium inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2545,Pentamidine non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2547,"Injection, peramivir",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2562,Plerixafor injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2597,Inj desmopressin acetate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2724,Protein c concentrate,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2730,Pralidoxime chloride inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2770,Quinupristin/dalfopristin,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2778,Ranibizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2783,Rasburicase,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2786,"Injection, reslizumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2790,Rho d immune globulin inj,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2791,Rhophylac injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2792,"Rho(d) immune globulin h, sd",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2793,Rilonacept injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2794,"Inj risperdal consta, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2796,Romiplostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2797,"Inj., rolapitant, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2798,"Inj., perseris, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2805,Sincalide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2820,Sargramostim injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2840,Inj sebelipase alfa 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2850,Inj secretin synthetic human,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2860,"Injection, siltuximab",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2993,Reteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J2997,Alteplase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3031,"Inj., fremanezumab-vfrm 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3032,Inj. eptinezumab-jjmr 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3060,"Inj, taliglucerase alfa 10 u",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3090,Inj tedizolid phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3095,Telavancin injection,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3101,Tenecteplase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3110,Teriparatide injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3111,Inj. romosozumab-aqqg 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3145,Testosterone undecanoate 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3240,Thyrotropin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3241,Inj. teprotumumab-trbw 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3243,Tigecycline injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3245,"Inj., tildrakizumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3246,Tirofiban hcl,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3262,Tocilizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3285,Treprostinil injection,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3300,Triamcinolone a inj prs-free,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3304,Inj triamcinolone ace xr 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3315,Triptorelin pamoate,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3316,"Inj., triptorelin xr 3.75 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3355,"Urofollitropin, 75 iu",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3357,"Ustekinumab sub cu inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3358,"Ustekinumab, iv inject, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3365,"Urokinase 250,000 iu inj",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3380,"Injection, vedolizumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3385,Velaglucerase alfa,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3396,Verteporfin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3397,"Inj., vestronidase alfa-vjbk",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3398,Inj luxturna 1 billion vec g,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3399,Inj onase abepar-xioi treat,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3470,Hyaluronidase injection,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3471,"Ovine, up to 999 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3472,"Ovine, 1000 usp units",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J3473,Hyaluronidase recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7169,"Inj andexxa, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7170,"Inj., emicizumab-kxwh 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7175,"Inj, factor x, (human), 1iu",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7177,"Inj., fibryga, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7178,Inj human fibrinogen con nos,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7179,Vonvendi inj 1 iu vwf:rco,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7180,Factor xiii anti-hem factor,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7181,Factor xiii recomb a-subunit,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7182,Factor viii recomb novoeight,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7183,Wilate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7185,Xyntha inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7186,Antihemophilic viii/vwf comp,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7187,"Humate-p, inj",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7188,Factor viii recomb obizur,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7189,Factor viia recomb novoseven,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7190,Factor viii,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7191,Factor viii (porcine),Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7192,Factor viii recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7193,Factor ix non-recombinant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7194,Factor ix complex,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7195,Factor ix recombinant nos,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7196,Antithrombin recombinant,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7197,Antithrombin iii injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7198,Anti-inhibitor,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7199,Hemophilia clot factor noc,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7200,Factor ix recombinan rixubis,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7201,Factor ix alprolix recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7202,Factor ix idelvion inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7203,Factor ix recomb gly rebinyn,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7204,Inj recombin esperoct per iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7205,Factor viii fc fusion recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7207,Factor viii pegylated recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7208,Inj. jivi 1 iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7209,Factor viii nuwiq recomb 1iu,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7210,"Inj, afstyla, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7211,"Inj, kovaltry, 1 i.u.",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7212,Factor viia recomb sevenfact,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7296,"Kyleena, 19.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7297,"Liletta, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7298,"Mirena, 52 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7300,Intraut copper contraceptive,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7301,"Skyla, 13.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7302,Levonorgestrel iu 52 mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7303,Contraceptive vaginal ring,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7304,Contraceptive hormone patch,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7306,Levonorgestrel implant sys,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7307,Etonogestrel implant system,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7308,Aminolevulinic acid hcl top,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7309,"Methyl aminolevulinate, top",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7310,Ganciclovir long act implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7311,"Inj., retisert, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7312,Dexamethasone intra implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7313,"Inj., iluvien, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7314,"Inj., yutiq, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7315,Ophthalmic mitomycin,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7316,"Inj, ocriplasmin, 0.125 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7318,"Inj, durolane 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7320,"Genvisc 850, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7321,Hyalgan or supartz inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7322,Hymovis injection 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7323,Euflexxa inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7324,Orthovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7325,Synvisc or synvisc-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7326,Gel-one,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7327,Monovisc inj per dose,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7328,Gelsyn-3 injection 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7329,"Inj, trivisc 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7330,Cultured chondrocytes implnt,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7331,"Synojoynt, inj., 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7332,"Inj., triluron, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7333,Visco-3 inj dose,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7336,Capsaicin 8% patch,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7340,Carbidopa levodopa ent 100ml,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7345,"Aminolevulinic acid, 10% gel",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7351,Inj bimatoprost itc imp1mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7352,"Afamelanotide implant, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7401,Mometasone furoate sinus imp,Chemotherapy and Pharmacotherapy,Per Unit,$384.11 ,OP,$384.11 ,$384.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7501,Azathioprine parenteral,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7504,Lymphocyte immune globulin,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7505,Monoclonal antibodies,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7511,Antithymocyte globuln rabbit,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7513,"Daclizumab, parenteral",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7525,Tacrolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7639,Dornase alfa non-comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7685,Tobramycin comp unit,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J7686,"Treprostinil, non-comp unit",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J8501,Oral aprepitant,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J8560,Etoposide oral 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J8562,Oral fludarabine phosphate,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J8565,Gefitinib oral,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J8655,"Oral netupitant, palonosetro",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J8670,"Rolapitant, oral, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J8705,Topotecan oral,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9010,Alemtuzumab injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9015,Aldesleukin injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9017,Arsenic trioxide injection,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9019,Erwinaze injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9020,"Asparaginase, nos",Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9022,"Inj, atezolizumab,10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9023,"Injection, avelumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9025,Azacitidine injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9027,Clofarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9030,Bcg live intravesical 1mg,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9031,Bcg live intravesical vac,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9032,"Injection, belinostat, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9033,"Inj., treanda 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9034,"Inj., bendeka 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9035,Bevacizumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9036,Inj. belrapzo/bendamustine,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9039,"Injection, blinatumomab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9040,Bleomycin sulfate injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9041,"Inj., velcade 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9042,Brentuximab vedotin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9043,Cabazitaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9044,"Inj, bortezomib, nos, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9047,"Injection, carfilzomib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9050,Carmustine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9055,Cetuximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9057,"Inj., copanlisib, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9065,Inj cladribine per 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9070,Cyclophosphamide 100 mg inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9098,Cytarabine liposome inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9118,Inj. calaspargase pegol-mknl,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9119,"Inj., cemiplimab-rwlc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9120,Dactinomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9144,"Daratumumab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9145,"Injection, daratumumab 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9150,Daunorubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9151,Daunorubicin citrate inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9153,"Inj daunorubicin, cytarabine",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9155,Degarelix injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9160,Denileukin diftitox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9171,Docetaxel injection,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9173,"Inj., durvalumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9176,"Injection, elotuzumab, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9177,Inj enfort vedo-ejfv 0.25mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9179,Eribulin mesylate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9185,Fludarabine phosphate inj,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9198,"Inj. infugem, 100 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9199,"Injection, infugem, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9200,Floxuridine injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9202,Goserelin acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9203,Gemtuzumab ozogamicin 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9204,"Inj mogamulizumab-kpkc, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9205,Inj irinotecan liposome 1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9207,Ixabepilone injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9208,Ifosfamide injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9210,"Inj., emapalumab-lzsg, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9211,Idarubicin hcl injection,Chemotherapy and Pharmacotherapy,Per Unit,$77.84 ,OP,$77.84 ,$77.84 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9213,Interferon alfa-2a inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9214,Interferon alfa-2b inj,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9216,Interferon gamma 1-b inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9217,Leuprolide acetate suspnsion,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9219,Leuprolide acetate implant,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9223,"Inj. lurbinectedin, 0.1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9225,Vantas implant,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9226,Supprelin la implant,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9227,Inj. isatuximab-irfc 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9228,Ipilimumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9229,Inj inotuzumab ozogam 0.1 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9230,Mechlorethamine hcl inj,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9245,Inj melpha hydroch nos 50 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9246,"Inj., evomela, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9261,Nelarabine injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9262,"Inj, omacetaxine mep, 0.01mg",Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9264,Paclitaxel protein bound,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9266,Pegaspargase injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9268,Pentostatin injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9269,Inj. tagraxofusp-erzs 10 mcg,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9270,Plicamycin (mithramycin) inj,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9271,Inj pembrolizumab,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9280,Mitomycin injection,Chemotherapy and Pharmacotherapy,Per Unit,$244.88 ,OP,$244.88 ,$244.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9281,Mitomycin instillation,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9285,"Inj, olaratumab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9293,Mitoxantrone hydrochl / 5 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9295,"Injection, necitumumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9299,"Injection, nivolumab",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9300,Gemtuzumab ozogamicin inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9301,Obinutuzumab inj,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9302,Ofatumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9303,Panitumumab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9304,"Inj. pemetrexed, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9305,Inj. pemetrexed nos 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9306,"Injection, pertuzumab, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9307,Pralatrexate injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9308,"Injection, ramucirumab",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9309,"Inj, polatuzumab vedotin 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$4,027.28 ",OP,"$4,027.28 ","$4,027.28 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9310,Rituximab injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9311,"Inj rituximab, hyaluronidase",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9312,"Inj., rituximab, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9313,"Inj., lumoxiti, 0.01 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9315,Romidepsin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9316,"Pertuzu, trastuzu, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9317,Sacituzumab govitecan-hziy,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9320,Streptozocin injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9325,Inj talimogene laherparepvec,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9328,Temozolomide injection,Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9330,Temsirolimus injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9340,Thiotepa injection,Chemotherapy and Pharmacotherapy,Per Unit,$189.67 ,OP,$189.67 ,$189.67 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9352,Injection trabectedin 0.1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9354,"Inj, ado-trastuzumab emt 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9355,Inj trastuzumab excl biosimi,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9356,"Inj. herceptin hylecta, 10mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9357,Valrubicin injection,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9358,Inj fam-trastu deru-nxki 1mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9371,"Inj, vincristine sul lip 1mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9395,"Injection, fulvestrant",Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9400,"Inj, ziv-aflibercept, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,J9600,Porfimer sodium injection,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,L8604,Dextranomer/hyaluronic acid,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,L8605,Inj bulking agent anal canal,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,L8607,Inj vocal cord bulking agent,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,M0239,Bamlanivimab-xxxx infusion,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,M0243,Casirivi and imdevi infusion,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P2028,Cephalin floculation test,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P2029,Congo red blood test,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P2031,Hair analysis,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P2033,Blood thymol turbidity,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P2038,Blood mucoprotein,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P3000,Screen pap by tech w md supv,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P3001,Screening pap smear by phys,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P7001,Culture bacterial urine,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9010,Whole blood for transfusion,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9011,Blood split unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9012,Cryoprecipitate each unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9016,Rbc leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9017,Plasma 1 donor frz w/in 8 hr,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9019,"Platelets, each unit",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9020,Plaelet rich plasma unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9021,Red blood cells unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9022,Washed red blood cells unit,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9023,"Frozen plasma, pooled, sd",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9031,Platelets leukocytes reduced,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9032,"Platelets, irradiated",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9033,Platelets leukoreduced irrad,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9034,"Platelets, pheresis",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9035,Platelet pheres leukoreduced,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9036,Platelet pheresis irradiated,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9037,Plate pheres leukoredu irrad,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9038,Rbc irradiated,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9039,Rbc deglycerolized,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9040,Rbc leukoreduced irradiated,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9041,"Albumin (human),5%, 50ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9043,"Plasma protein fract,5%,50ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9044,Cryoprecipitatereducedplasma,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9045,"Albumin (human), 5%, 250 ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9046,"Albumin (human), 25%, 20 ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9047,"Albumin (human), 25%, 50ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9048,"Plasmaprotein fract,5%,250ml",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9050,"Granulocytes, pheresis unit",Hematology,Per Unit,"$1,474.66 ",OP,"$1,474.66 ","$1,474.66 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9051,"Blood, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9052,"Platelets, hla-m, l/r, unit",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9053,"Plt, pher, l/r cmv-neg, irr",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9054,"Blood, l/r, froz/degly/wash",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9055,"Plt, aph/pher, l/r, cmv-neg",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9056,"Blood, l/r, irradiated",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9057,"Rbc, frz/deg/wsh, l/r, irrad",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9058,"Rbc, l/r, cmv-neg, irrad",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9059,"Plasma, frz between 8-24hour",Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9060,Fr frz plasma donor retested,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9070,Pathogen reduced plasma pool,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9071,Pathogen reduced plasma sing,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9072,Plate path red/rapid bac tes,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9073,Platelets pheresis path redu,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9099,Blood component/product noc,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,P9100,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0035,Cardiokymography,Cardiology,Per Unit,$14.69 ,OP,$14.69 ,$14.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0081,Infusion ther other than che,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0084,Chemotherapy by infusion,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0085,Chemo by both infusion and o,General Medicine,Per Unit,$178.41 ,OP,$178.41 ,$178.41 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0091,Obtaining screen pap smear,Pathology,Per Unit,$13.31 ,OP,$13.31 ,$13.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0111,Wet mounts/ w preparations,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0112,Potassium hydroxide preps,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0113,Pinworm examinations,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0114,Fern test,Laboratory,Per Unit,$2.86 ,OP,$2.86 ,$2.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0115,Post-coital mucous exam,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0138,"Ferumoxytol, non-esrd",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0139,"Ferumoxytol, esrd use",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0239,Bamlanivimab-xxxx,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0243,Casirivimab and imdevimab,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q0515,Sermorelin acetate injection,Chemotherapy and Pharmacotherapy,Per Unit,$518.96 ,OP,$518.96 ,$518.96 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2017,"Teniposide, 50 mg",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2028,"Inj, sculptra, 0.5mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2034,Agriflu vaccine,Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2035,"Afluria vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2036,"Flulaval vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2037,"Fluvirin vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2038,"Fluzone vacc, 3 yrs & >, im",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2039,"Influenza virus vaccine, nos",Preventive Care,Per Unit,$12.53 ,OP,$12.53 ,$12.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2040,Tisagenlecleucel car-pos t,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2043,Sipuleucel-t auto cd54+,Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2049,Imported lipodox inj,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q2050,Doxorubicin inj 10mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q3014,Telehealth facility fee,Ancillary Services,Per Unit,$8.33 ,OP,$8.33 ,$8.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q3027,Inj beta interferon im 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q3028,Inj beta interferon sq 1 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4074,Iloprost non-comp unit dose,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4081,"Epoetin alfa, 100 units esrd",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4100,"Skin substitute, nos",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4101,Apligraf,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4102,Oasis wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4103,Oasis burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4104,Integra bmwd,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4105,Integra drt or omnigraft,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4106,Dermagraft,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4107,Graftjacket,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4108,Integra matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4110,Primatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4111,Gammagraft,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4112,Cymetra injectable,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4113,Graftjacket xpress,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4114,Integra flowable wound matri,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4115,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4116,Alloderm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4117,Hyalomatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4118,Matristem micromatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4119,Matristem wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4120,Matristem burn matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4121,Theraskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4122,"Dermacell, awm, porous sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4123,Alloskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4124,Oasis tri-layer wound matrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4125,Arthroflex,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4126,Memoderm/derma/tranz/integup,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4127,Talymed,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4128,Flexhd/allopatchhd/matrixhd,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4129,Unite biomatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4130,Strattice tm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4131,Epifix or epicord,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4132,"Grafix core, grafixpl core",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4133,Grafix stravix prime pl sqcm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4134,Hmatrix,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4135,Mediskin,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4136,Ezderm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4137,Amnioexcel biodexcel 1sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4138,"Biodfence dryflex, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4139,"Amnio or biodmatrix, inj 1cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4140,Biodfence 1cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4141,"Alloskin ac, 1 cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4142,Xcm biologic tiss matrix 1cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4143,"Repriza, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4145,"Epifix, inj, 1mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4146,"Tensix, 1cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4147,Architect ecm px fx 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4148,Neox neox rt or clarix cord,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4149,"Excellagen, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4150,Allowrap ds or dry 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4151,"Amnioband, guardian 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4152,Dermapure 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4153,"Dermavest, plurivest sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4154,Biovance 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4155,Neoxflo or clarixflo 1 mg,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4156,Neox 100 or clarix 100,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4157,Revitalon 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4158,"Kerecis omega3, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4159,Affinity1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4160,Nushield 1 square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4161,Bio-connekt per square cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4162,"Wndex flw, bioskn flw, 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4163,"Woundex, bioskin, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4164,"Helicoll, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4165,"Keramatrix, kerasorb sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4166,"Cytal, per square centimeter",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4167,"Truskin, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4168,"Amnioband, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4169,"Artacent wound, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4170,"Cygnus, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4171,"Interfyl, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4172,Puraply or puraply am,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4173,Palingen or palingen xplus,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4174,Palingen or promatrx,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4175,Miroderm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4176,"Neopatch or therion, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4177,"Floweramnioflo, 0.1 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4178,"Floweramniopatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4179,"Flowerderm, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4180,"Revita, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4181,"Amnio wound, per square cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4182,"Transcyte, per sq centimeter",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4183,"Surgigraft, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4184,Cellesta or duo per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4185,Cellesta flowab amnion 0.5cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4186,Epifix 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4187,Epicord 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4188,Amnioarmor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4189,"Artacent ac, 1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4190,Artacent ac 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4191,Restorigin 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4192,"Restorigin, 1 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4193,Coll-e-derm 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4194,Novachor 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4195,Puraply 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4196,Puraply am 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4197,Puraply xt 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4198,Genesis amnio membrane 1sqcm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4200,Skin te 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4201,Matrion 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4202,"Keroxx (2.5g/cc), 1cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4203,"Derma-gide, 1 sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4204,Xwrap 1 sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4205,Membrane graft or wrap sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4206,Fluid flow or fluid gf 1 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4208,Novafix per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4209,Surgraft per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4210,Axolotl graf dualgraf sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4211,Amnion bio or axobio sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4212,"Allogen, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4213,"Ascent, 0.5 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4214,Cellesta cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4215,"Axolotl ambient, cryo 0.1 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4216,Artacent cord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4217,Woundfix biowound plus xplus,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4218,Surgicord per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4219,Surgigraft dual per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4220,"Bellacell hd, surederm sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4221,Amniowrap2 per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4222,"Progenamatrix, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4226,Myown harv prep proc sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4227,Amniocore per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4228,"Bionextpatch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4229,Cogenex amnio memb per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4230,Cogenex flow amnion 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4231,"Corplex p, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4232,"Corplex, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4233,Surfactor /nudyn per 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4234,"Xcellerate, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4235,Amniorepair or altiply sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4236,Carepatch per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4237,"Cryo-cord, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4238,"Derm-maxx, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4239,Amnio-maxx or lite per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4240,Corecyte topical only 0.5 cc,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4241,"Polycyte, topical only 0.5cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4242,"Amniocyte plus, per 0.5 cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4244,"Procenta, per 200 mg",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4245,"Amniotext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4246,"Coretext or protext, per cc",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4247,"Amniotext patch, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4248,Dermacyte amn mem allo sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4249,"Amniply, per sq cm",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4250,Amnioamp-mp per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4254,Novafix dl per sq cm,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q4255,"Reguard, topical use per sq",DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5101,"Injection, zarxio",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5102,"Inj., infliximab biosimilar",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5103,"Injection, inflectra",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5104,"Injection, renflexis",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5105,Inj retacrit esrd on dialysi,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5106,Inj retacrit non-esrd use,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5107,Inj mvasi 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5108,"Injection, fulphila",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5109,"Injection, ixifi, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5110,Nivestym,Chemotherapy and Pharmacotherapy,Per Unit,$182.12 ,OP,$182.12 ,$182.12 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5111,"Injection, udenyca 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5112,Inj ontruzant 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5113,Inj herzuma 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5114,Inj ogivri 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5115,Inj truxima 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5116,"Inj., trazimera, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5117,"Inj., kanjinti, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5118,"Inj., zirabev, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5119,"Inj ruxience, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5120,Inj pegfilgrastim-bmez 0.5mg,Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5121,"Inj. avsola, 10 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$1,236.31 ",OP,"$1,236.31 ","$1,236.31 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q5122,"Inj, nyvepria",Chemotherapy and Pharmacotherapy,Per Unit,"$1,836.04 ",OP,"$1,836.04 ","$1,836.04 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9975,Factor VIII FC Fusion Recomb,Chemotherapy and Pharmacotherapy,Per Unit,"$2,528.43 ",OP,"$2,528.43 ","$2,528.43 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9979,"Injection, Alemtuzumab",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9980,"Genvisc, inj, 1mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9984,Kyleena,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9987,Pathogen test for platelets,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9988,Platelet pheresis path reduc,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9989,"Ustekinumab IV Inj, 1 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9991,Buprenorph xr 100 mg or less,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9992,Buprenorphine xr over 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$814.32 ,OP,$814.32 ,$814.32 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9993,"Inj., triamcinolone ext rel",Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,Q9995,"inj. emicizumab-kxwh, 0.5 mg",Chemotherapy and Pharmacotherapy,Per Unit,"$10,767.37 ",OP,"$10,767.37 ","$10,767.37 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0013,"Esketamine, nasal spray",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0040,"Injection, ticarcillin disod",Chemotherapy and Pharmacotherapy,Per Unit,$855.06 ,OP,$855.06 ,$855.06 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0088,Imatinib 100 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0126,Inj follitropin alfa 75 iu,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0132,Inj ganirelix acetat 250 mcg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0140,"Saquinavir, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0142,Colistimethate inh sol mg,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0145,Peg interferon alfa-2a/180,Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0148,Peg interferon alfa-2b/10,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0155,Epoprostenol dilutant,Chemotherapy and Pharmacotherapy,Per Unit,$99.44 ,OP,$99.44 ,$99.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0166,Inj olanzapine 2.5mg,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0175,Flutamide 125 mg,Chemotherapy and Pharmacotherapy,Per Unit,$100.71 ,OP,$100.71 ,$100.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0178,Lomustine 10 mg,Chemotherapy and Pharmacotherapy,Per Unit,$233.27 ,OP,$233.27 ,$233.27 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0190,"Mifepristone, oral, 200 mg",Chemotherapy and Pharmacotherapy,Per Unit,$45.71 ,OP,$45.71 ,$45.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0195,Pneumo vaccine 5-9 yrs,Preventive Care,Per Unit,$52.77 ,OP,$52.77 ,$52.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0199,Med abortion inc all ex drug,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0201,Partial hospitalization serv,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0220,Medical conference by physic,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0221,"Medical conference, 60 min",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0250,Comp geriatr assmt team,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0257,End of life counseling,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0271,Home hospice case 30 days,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0280,"Medical home, initial plan",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0281,"Medical home, maintenance",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0311,Comp mgmt care coord adv ill,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0315,Disease management program,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0316,Follow-up/reassessment,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0340,Lifestyle mod 1st stage,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0353,Cancer treatmentplan initial,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0354,Cancer treatment plan change,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0390,Rout foot care per visit,General Surgery,Per Unit,$46.77 ,OP,$46.77 ,$46.77 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0395,Impression casting ft,Orthopedics,Per Unit,$185.40 ,OP,$185.40 ,$185.40 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0592,Comp cont lens eval,Ophthalmology,Per Unit,$27.36 ,OP,$27.36 ,$27.36 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0601,Screening proctoscopy,Preventive Care,Per Unit,$387.00 ,OP,$387.00 ,$387.00 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0618,Audiometry for hearing aid,Otolaryngology,Per Unit,$78.72 ,OP,$78.72 ,$78.72 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0800,Laser in situ keratomileusis,Ophthalmology Surgery,Per Unit,$751.45 ,OP,$751.45 ,$751.45 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0810,Photorefractive keratectomy,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S0812,Phototherap keratect,Ophthalmology Surgery,Per Unit,"$1,197.94 ",OP,"$1,197.94 ","$1,197.94 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2066,Breast gap flap reconst,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2067,"Breast ""stacked"" diep/gap",General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2068,Breast diep or siea flap,General Surgery,Per Unit,"$2,963.62 ",OP,"$2,963.62 ","$2,963.62 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2083,Adjustment gastric band,Gastroenterology,Per Unit,$119.18 ,OP,$119.18 ,$119.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2112,Knee arthroscp harv,Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2202,Echosclerotherapy,Vascular Surgery,Per Unit,$500.46 ,OP,$500.46 ,$500.46 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2225,Myringotomy laser-assist,Otolaryngology Surgery,Per Unit,$729.78 ,OP,$729.78 ,$729.78 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2230,Implant semi-imp hear,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2235,Implant auditory brain imp,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2260,Induced abortion 17-24 weeks,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2265,Induced abortion 25-28 wks,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2266,Induced abortion 29-31 wks,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2267,Induced abortion 32 or more,Obstetrics,Per Unit,$983.66 ,OP,$983.66 ,$983.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2300,"Arthroscopy, shoulder, surgi",Orthopedic Surgery,Per Unit,"$1,170.79 ",OP,"$1,170.79 ","$1,170.79 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2340,Chemodenervation of abductor,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2341,Chemodenerv adduct vocal,Otolaryngology Surgery,Per Unit,"$1,283.26 ",OP,"$1,283.26 ","$1,283.26 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2342,Nasal endoscop po debrid,Otolaryngology Surgery,Per Unit,$230.30 ,OP,$230.30 ,$230.30 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2400,Fetal surg congen hernia,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2401,Fetal surg urin trac obstr,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2402,Fetal surg cong cyst malf,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2403,Fetal surg pulmon sequest,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2404,Fetal surg myelomeningo,Obstetrics,Per Unit,$482.07 ,OP,$482.07 ,$482.07 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2405,Fetal surg sacrococ teratoma,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2409,Fetal surg noc,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S2411,Fetoscop laser ther ttts,Obstetrics,Per Unit,$139.58 ,OP,$139.58 ,$139.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3620,Newborn metabolic screening,Laboratory,Per Unit,$5.86 ,OP,$5.86 ,$5.86 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3630,Eosinophil blood count,Laboratory,Per Unit,$3.99 ,OP,$3.99 ,$3.99 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3645,Hiv-1 antibody testing of or,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3650,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3652,"Saliva test, hormone level;",Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3655,Antisperm antibodies test,Laboratory,Per Unit,$5.75 ,OP,$5.75 ,$5.75 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3708,Gastrointestinal fat absorpt,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3721,Pca3 testing,Laboratory,Per Unit,$6.42 ,OP,$6.42 ,$6.42 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3722,Dose optimization auc - 5fu,Laboratory,Per Unit,$7.38 ,OP,$7.38 ,$7.38 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3800,Genetic testing als,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3840,Dna analysis ret-oncogene,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3841,Gene test retinoblastoma,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3842,Gene test hippel-lindau,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3844,Dna analysis deafness,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3845,Gene test alpha-thalassemia,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3846,Gene test beta-thalassemia,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3849,Gene test niemann-pick,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3850,Gene test sickle cell,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3852,Dna analysis apoe alzheimer,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3853,Gene test myo musclr dyst,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3854,Gene profile panel breast,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3861,Genetic test brugada,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3865,Comp genet test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3866,Spec gene test hyp cardiomy,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3870,Cgh test developmental delay,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3890,Fecal dna analysis,Laboratory,Per Unit,$22.80 ,OP,$22.80 ,$22.80 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3900,Surface emg,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3902,Ballistocardiogram,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S3904,Masters two step,Cardiology,Per Unit,$80.87 ,OP,$80.87 ,$80.87 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4011,Ivf package,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4013,Compl gift case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4014,Compl zift case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4015,Complete ivf nos case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4016,Frozen ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4017,Ivf canc a stim case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4018,F emb trns canc case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4020,Ivf canc a aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4021,Ivf canc p aspir case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4022,Asst oocyte fert case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4023,Incompl donor egg case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4025,Donor serv ivf case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4026,Procure donor sperm,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4027,Store prev froz embryos,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4028,Microsurg epi sperm asp,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4030,Sperm procure init visit,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4031,Sperm procure subs visit,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4035,Stimulated iui case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4037,Cryo embryo transf case rate,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4040,Monit store cryo embryo 30 d,Obstetrics,Per Unit,$175.09 ,OP,$175.09 ,$175.09 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4042,Ovulation mgmt per cycle,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4981,Insert levonorgestrel ius,Gynecology,Per Unit,$102.34 ,OP,$102.34 ,$102.34 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S4989,Contracept iud,Chemotherapy and Pharmacotherapy,Per Unit,$191.26 ,OP,$191.26 ,$191.26 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S5180,Hh respiratory thrpy in eval,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S5181,Hh respiratory thrpy nos/day,Pulmonary,Per Unit,$138.31 ,OP,$138.31 ,$138.31 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8032,Low dose CT lung screening,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8035,Magnetic source imaging,Diagnostic Radiology,Per Unit,$133.33 ,OP,$133.33 ,$133.33 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8037,Mrcp,Interventional Radiology,Per Unit,$224.69 ,OP,$224.69 ,$224.69 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8055,Us guidance fetal reduct,Interventional Radiology,Per Unit,$63.29 ,OP,$63.29 ,$63.29 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8080,Scintimammography,Diagnostic Nuclear Medicine,Per Unit,$239.98 ,OP,$239.98 ,$239.98 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8092,Electron beam computed tomog,Diagnostic Radiology,Per Unit,$79.18 ,OP,$79.18 ,$79.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8110,Peak expiratory flow rate (p,Pulmonary,Per Unit,$42.64 ,OP,$42.64 ,$42.64 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8930,Auricular electrostimulation,Neurology,Per Unit,$187.24 ,OP,$187.24 ,$187.24 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8940,Hippotherapy per session,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8948,Low-level laser trmt 15 min,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8950,"Complex lymphedema therapy,",Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S8990,Pt or manip for maint,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9015,Automated eeg monitoring,Neurology,Per Unit,$147.66 ,OP,$147.66 ,$147.66 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9024,Paranasal sinus ultrasound,Diagnostic Radiology,Per Unit,$86.73 ,OP,$86.73 ,$86.73 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9061,Medical supplies and equipme,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9090,Vertebral axial decompressio,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9098,Home phototherapy visit,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9128,"Speech therapy, in the home,",Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9129,"Occupational therapy, in the",Rehabilitation,Per Unit,$306.55 ,OP,$306.55 ,$306.55 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9131,Pt in the home per diem,Rehabilitation,Per Unit,$192.71 ,OP,$192.71 ,$192.71 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9140,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9141,"Diabetic management program,",Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9145,Insulin pump initiation,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9152,"Speech therapy, re-eval",Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9211,Home mgmt gest hypertension,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9213,Hm preeclamp per diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9214,Hm gest dm per diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9335,Ht hemodialysis diem,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9339,Hit periton dialysis diem,Nephrology,Per Unit,$540.95 ,OP,$540.95 ,$540.95 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9370,Ht inj antiemetic diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9372,Ht inj anticoag diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9445,Pt education noc individ,Preventive Care,Per Unit,$20.58 ,OP,$20.58 ,$20.58 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9446,Pt education noc group,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9452,Nutrition class,Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9453,Smoking cessation class,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9455,"Diabetic management program,",Preventive Care,Per Unit,$26.23 ,OP,$26.23 ,$26.23 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9465,"Diabetic management program,",Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9470,"Nutritional counseling, diet",Ancillary Services,Per Unit,$100.15 ,OP,$100.15 ,$100.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9472,Cardiac rehabilitation progr,Rehabilitation,Per Unit,$274.82 ,OP,$274.82 ,$274.82 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9473,Pulmonary rehabilitation pro,Rehabilitation,Per Unit,$73.11 ,OP,$73.11 ,$73.11 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9475,Ambulatory setting substance,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9476,Vestibular rehab per diem,Rehabilitation,Per Unit,$142.44 ,OP,$142.44 ,$142.44 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9480,Intensive outpatient psychia,Behavioral Health,Per Unit,$339.88 ,OP,$339.88 ,$339.88 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9482,Family stabilization 15 min,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9484,Crisis intervention per hour,Behavioral Health,Per Unit,$135.70 ,OP,$135.70 ,$135.70 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9485,Crisis intervention mental h,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9537,Ht hem horm inj diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9538,Hit blood products diem,Hematology,Per Unit,$378.53 ,OP,$378.53 ,$378.53 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9558,Ht inj growth horm diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9559,Hit inj interferon diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9560,Ht inj hormone diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,S9562,Ht inj palivizumab diem,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,T1006,Family/couple counseling,Behavioral Health,Per Unit,$89.14 ,OP,$89.14 ,$89.14 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,T1007,Treatment plan development,Behavioral Health,Per Unit,$94.47 ,OP,$94.47 ,$94.47 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,T1012,Alcohol/substance abuse skil,Behavioral Health,Per Unit,$48.15 ,OP,$48.15 ,$48.15 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,T1016,Case management,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,T1017,Targeted case management,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,T1023,Program intake assessment,Behavioral Health,Per Unit,$70.18 ,OP,$70.18 ,$70.18 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,T1040,Comm bh clinic svc per diem,Behavioral Health,Per Unit,$220.60 ,OP,$220.60 ,$220.60 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,T2022,"Case management, per month",Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,T2023,Targeted case mgmt per month,Ancillary Services,Per Unit,$69.37 ,OP,$69.37 ,$69.37 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,U0001,2019-ncov diagnostic p,Laboratory,Per Unit,$15.25 ,OP,$15.25 ,$15.25 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,U0002,Covid-19 lab test non-cdc,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,U0005,Infec agen detec ampli probe,Laboratory,Per Unit,$4.59 ,OP,$4.59 ,$4.59 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,V2785,Corneal tissue processing,Ophthalmology,Per Unit,"$1,390.89 ",OP,"$1,390.89 ","$1,390.89 ",,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,V2790,Amniotic membrane,DME and Supplies,Per Unit,$263.49 ,OP,$263.49 ,$263.49 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,V5362,Speech screening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,V5363,Language screening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
Molina Healthcare of IL MCD,CPT,V5364,Dysphagia screening,Rehabilitation,Per Unit,$15.74 ,OP,$15.74 ,$15.74 ,,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-001,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","463,441.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-002,HEART TRANSPLANT OR IMPLANT OF HEART ASSIST SYSTEM W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","254,896.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-003,ECMO OR TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITH MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","303,857.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-004,TRACHEOSTOMY WITH MV >96 HOURS OR PRINCIPAL DIAGNOSIS EXCEPT FACE- MOUTH AND NECK WITHOUT MAJOR O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","189,792.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-005,LIVER TRANSPLANT W MCC OR INTESTINAL TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","163,572.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-006,LIVER TRANSPLANT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","75,067.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-007,LUNG TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","185,188.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-008,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,828.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-010,PANCREAS TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,883.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-011,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,262.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-012,TRACHEOSTOMY FOR FACE- MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,310.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-013,TRACHEOSTOMY FOR FACE - MOUTH AND NECK DIAGNOSES OR LARYNGECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,528.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-014,ALLOGENEIC BONE MARROW TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","204,460.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-016,AUTOLOGOUS BONE MARROW TRANSPLANT WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","107,619.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-017,AUTOLOGOUS BONE MARROW TRANSPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,283.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-018,CHIMERIC ANTIGEN RECEPTOR (CAR) T-CELL AND OTHER IMMUNOTHERAPIES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","597,264.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-019,SIMULTANEOUS PANCREAS AND KIDNEY TRANSPLANT WITH HEMODIALYSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","106,590.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-020,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","165,121.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-021,INTRACRANIAL VASCULAR PROCEDURES WITH PRINCIPAL DIAGNOSIS HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","120,505.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-022,INTRACRANIAL VASCULAR PROCEDURES W PDX HEMORRHAGE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,753.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-023,CRANIO W MAJOR DEV IMPL/ACUTE COMPLEX CNS PDX W MCC OR CHEMO IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,596.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-024,CRANIOTOMY WITH MAJOR DEVICE IMPLANT OR ACUTE COMPLEX CNS PRINCIPAL DIAGNOSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,920.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-025,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","71,867.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-026,CRANIOTOMY & ENDOVASCULAR INTRACRANIAL PROCEDURES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,928.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-027,CRANIOTOMY AND ENDOVASCULAR INTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,188.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-028,SPINAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","93,120.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-029,SPINAL PROCEDURES WITH CC OR SPINAL NEUROSTIMULATORS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,720.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-030,SPINAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,713.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-031,VENTRICULAR SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,857.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-032,VENTRICULAR SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,395.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-033,VENTRICULAR SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,531.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-034,CAROTID ARTERY STENT PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,593.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-035,CAROTID ARTERY STENT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,393.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-036,CAROTID ARTERY STENT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,619.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-037,EXTRACRANIAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,395.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-038,EXTRACRANIAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,516.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-039,EXTRACRANIAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,224.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-040,PERIPHERAL- CRANIAL NERVE AND OTHER NERVOUS SYSTEM PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,324.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-041,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W CC OR PERIPH NEUROSTIM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,617.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-042,PERIPH/CRANIAL NERVE & OTHER NERV SYST PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,158.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-052,SPINAL DISORDERS AND INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,521.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-053,SPINAL DISORDERS AND INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,177.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-054,NERVOUS SYSTEM NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,852.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-055,NERVOUS SYSTEM NEOPLASMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,694.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-056,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,996.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-057,DEGENERATIVE NERVOUS SYSTEM DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,227.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-058,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,787.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-059,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,024.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-060,MULTIPLE SCLEROSIS AND CEREBELLAR ATAXIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,649.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-061,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,211.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-062,ISCHEMIC STROKE - PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,795.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-063,ISCHEMIC STROKE- PRECEREBRAL OCCLUSION OR TRANSIENT ISCHEMIA WITH THROMBOLYTIC AGENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,358.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-064,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,608.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-065,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,291.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-066,INTRACRANIAL HEMORRHAGE OR CEREBRAL INFARCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,374.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-067,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,793.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-068,NONSPECIFIC CVA AND PRECEREBRAL OCCLUSION WITHOUT INFARCTION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,217.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-069,TRANSIENT ISCHEMIA WITHOUT THROMBOLYTIC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,577.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-070,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,822.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-071,NONSPECIFIC CEREBROVASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,172.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-072,NONSPECIFIC CEREBROVASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,339.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-073,CRANIAL AND PERIPHERAL NERVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,190.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-074,CRANIAL AND PERIPHERAL NERVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,294.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-075,VIRAL MENINGITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,016.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-076,VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,694.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-077,HYPERTENSIVE ENCEPHALOPATHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,510.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-078,HYPERTENSIVE ENCEPHALOPATHY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,184.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-079,HYPERTENSIVE ENCEPHALOPATHY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,628.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-080,NONTRAUMATIC STUPOR & COMA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,472.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-081,NONTRAUMATIC STUPOR & COMA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,352.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-082,TRAUMATIC STUPOR AND COMA >1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,129.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-083,TRAUMATIC STUPOR AND COMA >1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,467.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-084,TRAUMATIC STUPOR AND COMA >1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,467.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-085,TRAUMATIC STUPOR AND COMA <1 HOUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,902.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-086,TRAUMATIC STUPOR AND COMA <1 HOUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,366.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-087,TRAUMATIC STUPOR AND COMA <1 HOUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,801.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-088,CONCUSSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,348.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-089,CONCUSSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,979.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-090,CONCUSSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,676.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-091,OTHER DISORDERS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,382.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-092,OTHER DISORDERS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,777.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-093,OTHER DISORDERS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,500.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-094,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,129.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-095,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,128.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-096,BACTERIAL AND TUBERCULOUS INFECTIONS OF NERVOUS SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,304.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-097,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,041.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-098,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,774.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-099,NON-BACTERIAL INFECTION OF NERVOUS SYSTEM EXCEPT VIRAL MENINGITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,356.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-100,SEIZURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,977.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-101,SEIZURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,192.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-102,HEADACHES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,427.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-103,HEADACHES W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,251.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-113,ORBITAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,068.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-114,ORBITAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,128.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-115,EXTRAOCULAR PROCEDURES EXCEPT ORBIT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,252.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-116,INTRAOCULAR PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,035.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-117,INTRAOCULAR PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,622.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-121,ACUTE MAJOR EYE INFECTIONS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,019.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-122,ACUTE MAJOR EYE INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,300.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-123,NEUROLOGICAL EYE DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,244.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-124,OTHER DISORDERS OF THE EYE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,380.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-125,OTHER DISORDERS OF THE EYE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,366.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-135,SINUS AND MASTOID PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,249.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-136,SINUS AND MASTOID PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,088.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-137,MOUTH PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,497.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-138,MOUTH PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,489.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-139,SALIVARY GLAND PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,628.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-140,MAJOR HEAD AND NECK PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,689.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-141,MAJOR HEAD AND NECK PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,320.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-142,MAJOR HEAD AND NECK PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,740.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-143,OTHER EAR- NOSE- MOUTH AND THROAT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,420.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-144,HERNIA PROCEDURES AGE 0-17,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,008.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-145,OTHER EAR - NOSE - MOUTH AND THROAT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,416.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-146,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,529.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-147,EAR- NOSE- MOUTH AND THROAT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,817.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-148,EAR - NOSE - MOUTH & THROAT MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,580.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-149,DYSEQUILIBRIUM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,768.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-150,EPISTAXIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,195.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-151,EPISTAXIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,792.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-152,OTITIS MEDIA AND URI WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,230.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-153,OTITIS MEDIA AND URI WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,369.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-154,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,680.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-155,OTHER EAR- NOSE- MOUTH AND THROAT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,508.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-156,OTHER EAR - NOSE - MOUTH AND THROAT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,521.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-157,DENTAL AND ORAL DISEASES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,158.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-158,DENTAL AND ORAL DISEASES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,225.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-159,DENTAL AND ORAL DISEASES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,492.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-163,MAJOR CHEST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","79,377.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-164,MAJOR CHEST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,227.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-165,MAJOR CHEST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,617.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-166,OTHER RESP SYSTEM O.R. PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,660.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-167,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,790.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-168,OTHER RESPIRATORY SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,905.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-175,PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,707.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-176,PULMONARY EMBOLISM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,187.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-177,RESPIRATORY INFECTIONS & INFLAMMATIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,524.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-178,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,294.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-179,RESPIRATORY INFECTIONS AND INFLAMMATIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,937.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-180,RESPIRATORY NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,804.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-181,RESPIRATORY NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,934.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-182,RESPIRATORY NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,600.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-183,MAJOR CHEST TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,889.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-184,MAJOR CHEST TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,630.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-185,MAJOR CHEST TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,377.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-186,PLEURAL EFFUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,691.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-187,PLEURAL EFFUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,515.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-188,PLEURAL EFFUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,649.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-189,PULMONARY EDEMA AND RESPIRATORY FAILURE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,596.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-190,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,982.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-191,CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,129.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-192,CHRONIC OBSTRUCTIVE PULMONARY DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,118.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-193,SIMPLE PNEUMONIA & PLEURISY W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,971.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-194,SIMPLE PNEUMONIA AND PLEURISY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,808.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-195,SIMPLE PNEUMONIA AND PLEURISY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,640.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-196,INTERSTITIAL LUNG DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,777.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-197,INTERSTITIAL LUNG DISEASE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,089.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-198,INTERSTITIAL LUNG DISEASE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,876.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-199,PNEUMOTHORAX WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,601.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-200,PNEUMOTHORAX WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,200.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-201,PNEUMOTHORAX WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,352.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-202,BRONCHITIS AND ASTHMA WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,449.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-203,BRONCHITIS AND ASTHMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,288.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-204,RESPIRATORY SIGNS AND SYMPTOMS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,680.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-205,OTHER RESPIRATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,916.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-206,OTHER RESPIRATORY SYSTEM DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,147.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-207,RESPIRATORY SYSTEM DIAGNOSIS W VENTILATOR SUPPORT 96+ HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,622.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-208,RESPIRATORY SYSTEM DIAGNOSIS WITH VENTILATOR SUPPORT <=96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,676.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-215,OTHER HEART ASSIST SYSTEM IMPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","178,526.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-216,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","166,881.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-217,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","103,884.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-218,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITH CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,291.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-219,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","128,881.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-220,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,398.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-221,CARDIAC VALVE AND OTHER MAJOR CARDIOTHORACIC PROCEDURES WITHOUT CARDIAC CATHETERIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,836.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-222,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","134,737.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-223,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITH AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","99,393.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-224,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","117,795.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-225,CARDIAC DEFIBRILLATOR IMPLANT WITH CARDIAC CATHETERIZATION WITHOUT AMI- HF OR SHOCK WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,028.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-226,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","105,788.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-227,CARDIAC DEFIBRILLATOR IMPLANT WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","84,030.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-228,OTHER CARDIOTHORACIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","99,444.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-229,OTHER CARDIOTHORACIC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,808.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-231,CORONARY BYPASS W PTCA W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","135,843.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-232,CORONARY BYPASS W PTCA W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","94,372.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-233,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","124,683.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-234,CORONARY BYPASS WITH CARDIAC CATHETERIZATION OR OPEN ABLATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,078.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-235,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","96,483.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-236,CORONARY BYPASS WITHOUT CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","65,292.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-239,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","76,939.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-240,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,638.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-241,AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS EXCEPT UPPER LIMB AND TOE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,462.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-242,PERMANENT CARDIAC PACEMAKER IMPLANT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,560.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-243,PERMANENT CARDIAC PACEMAKER IMPLANT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,521.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-244,PERMANENT CARDIAC PACEMAKER IMPLANT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,051.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-245,AICD GENERATOR PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,624.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-246,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,011.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-247,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,811.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-248,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITH MCC OR 4+ ARTERIES OR STENTS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,782.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-249,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITH NON-DRUG-ELUTING STENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,068.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-250,PERCUTANEOUS CARDIOVASCULAR PROCEDURES WITHOUT CORONARY ARTERY STENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,364.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-251,PERC CARDIOVASC PROC W/O CORONARY ARTERY STENT W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,556.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-252,OTHER VASCULAR PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,131.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-253,OTHER VASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,459.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-254,OTHER VASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,952.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-255,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,688.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-256,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,289.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-257,UPPER LIMB AND TOE AMPUTATION FOR CIRCULATORY SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,576.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-258,CARDIAC PACEMAKER DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,220.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-259,CARDIAC PACEMAKER DEVICE REPLACEMENT WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,923.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-260,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,347.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-261,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,860.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-262,CARDIAC PACEMAKER REVISION EXCEPT DEVICE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,329.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-263,VEIN LIGATION AND STRIPPING,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,884.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-264,OTHER CIRCULATORY SYSTEM O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,964.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-265,AICD LEAD PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,803.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-266,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","113,555.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-267,ENDOVASCULAR CARDIAC VALVE REPLACEMENT AND SUPPLEMENT PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","89,614.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-268,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","111,273.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-269,AORTIC AND HEART ASSIST PROCEDURES EXCEPT PULSATION BALLOON WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,033.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-270,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,905.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-271,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,033.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-272,OTHER MAJOR CARDIOVASCULAR PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,020.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-273,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,395.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-274,PERCUTANEOUS AND OTHER INTRACARDIAC PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,566.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-280,ACUTE MYOCARDIAL INFARCTION - DISCHARGED ALIVE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,019.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-281,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,913.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-282,ACUTE MYOCARDIAL INFARCTION- DISCHARGED ALIVE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,608.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-283,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,833.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-284,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,747.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-285,ACUTE MYOCARDIAL INFARCTION- EXPIRED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","7,942.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-286,CIRCULATORY DISORDERS EXCEPT AMI- WITH CARDIAC CATHETERIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,425.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-287,CIRCULATORY DISORDERS EXCEPT AMI - WITH CARDIAC CATHETERIZATION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,400.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-288,ACUTE & SUBACUTE ENDOCARDITIS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,896.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-289,ACUTE AND SUBACUTE ENDOCARDITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,281.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-290,ACUTE AND SUBACUTE ENDOCARDITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,377.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-291,HEART FAILURE AND SHOCK WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,454.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-292,HEART FAILURE AND SHOCK WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,321.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-293,HEART FAILURE AND SHOCK WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,441.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-294,DEEP VEIN THROMBOPHLEBITIS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,513.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-295,DEEP VEIN THROMBOPHLEBITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,700.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-296,CARDIAC ARREST - UNEXPLAINED W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,516.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-297,CARDIAC ARREST- UNEXPLAINED WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,273.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-298,CARDIAC ARREST- UNEXPLAINED WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","7,811.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-299,PERIPHERAL VASCULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,502.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-300,PERIPHERAL VASCULAR DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,675.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-301,PERIPHERAL VASCULAR DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,880.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-302,ATHEROSCLEROSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,496.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-303,ATHEROSCLEROSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,822.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-304,HYPERTENSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,529.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-305,HYPERTENSION WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,816.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-306,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,059.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-307,CARDIAC CONGENITAL AND VALVULAR DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,894.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-308,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,188.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-309,CARDIAC ARRHYTHMIA AND CONDUCTION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,990.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-310,CARDIAC ARRHYTHMIA & CONDUCTION DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,934.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-311,ANGINA PECTORIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,152.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-312,SYNCOPE AND COLLAPSE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,395.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-313,CHEST PAIN,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,532.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-314,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,334.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-315,OTHER CIRCULATORY SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,603.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-316,OTHER CIRCULATORY SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,992.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-319,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","69,052.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-320,OTHER ENDOVASCULAR CARDIAC VALVE PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,099.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-326,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","86,043.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-327,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","41,753.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-328,STOMACH- ESOPHAGEAL AND DUODENAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,648.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-329,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","77,604.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-330,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,624.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-331,MAJOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,361.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-332,RECTAL RESECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","66,555.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-333,RECTAL RESECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,256.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-334,RECTAL RESECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,747.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-335,PERITONEAL ADHESIOLYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,246.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-336,PERITONEAL ADHESIOLYSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,526.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-337,PERITONEAL ADHESIOLYSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,121.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-338,APPENDECTOMY WITH COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,780.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-339,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,120.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-340,APPENDECTOMY W COMPLICATED PRINCIPAL DIAG W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,654.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-341,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,059.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-342,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,929.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-343,APPENDECTOMY WITHOUT COMPLICATED PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,750.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-344,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,814.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-345,MINOR SMALL AND LARGE BOWEL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,243.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-346,MINOR SMALL AND LARGE BOWEL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,400.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-347,ANAL AND STOMAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,385.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-348,ANAL AND STOMAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,478.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-349,ANAL AND STOMAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,668.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-350,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,238.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-351,INGUINAL AND FEMORAL HERNIA PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,846.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-352,INGUINAL AND FEMORAL HERNIA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,648.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-353,HERNIA PROCEDURES EXCEPT INGUINAL AND FEMORAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,132.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-354,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,528.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-355,HERNIA PROCEDURES EXCEPT INGUINAL & FEMORAL W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,747.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-356,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,662.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-357,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,059.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-358,OTHER DIGESTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,424.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-368,MAJOR ESOPHAGEAL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,076.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-369,MAJOR ESOPHAGEAL DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,228.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-370,MAJOR ESOPHAGEAL DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,961.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-371,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,652.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-372,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,441.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-373,MAJOR GASTROINTESTINAL DISORDERS AND PERITONEAL INFECTIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,896.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-374,DIGESTIVE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,086.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-375,DIGESTIVE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,278.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-376,DIGESTIVE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,323.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-377,GASTROINTESTINAL HEMORRHAGE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,782.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-378,GASTROINTESTINAL HEMORRHAGE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,891.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-379,GASTROINTESTINAL HEMORRHAGE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,193.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-380,COMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,129.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-381,COMPLICATED PEPTIC ULCER WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,955.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-382,COMPLICATED PEPTIC ULCER WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,292.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-383,UNCOMPLICATED PEPTIC ULCER WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,974.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-384,UNCOMPLICATED PEPTIC ULCER WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,278.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-385,INFLAMMATORY BOWEL DISEASE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,905.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-386,INFLAMMATORY BOWEL DISEASE W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,896.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-387,INFLAMMATORY BOWEL DISEASE W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,416.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-388,GASTROINTESTINAL OBSTRUCTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,188.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-389,GASTROINTESTINAL OBSTRUCTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,148.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-390,GASTROINTESTINAL OBSTRUCTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,321.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-391,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,910.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-392,ESOPHAGITIS- GASTROENTERITIS AND MISCELLANEOUS DIGESTIVE DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,230.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-393,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,457.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-394,OTHER DIGESTIVE SYSTEM DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,017.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-395,OTHER DIGESTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,395.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-405,PANCREAS- LIVER AND SHUNT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,688.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-406,PANCREAS - LIVER AND SHUNT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,032.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-407,PANCREAS - LIVER AND SHUNT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,856.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-408,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,992.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-409,BILIARY TRACT PROCEDURES EXCEPT ONLY CHOLECYSTECTOMY WITH OR WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,828.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-410,BILIARY TRACT PROC EXCEPT ONLY CHOLECYST W OR W/O C.D.E. W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,051.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-411,CHOLECYSTECTOMY W C.D.E. W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","60,038.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-412,CHOLECYSTECTOMY WITH C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,411.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-413,CHOLECYSTECTOMY WITH C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,702.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-414,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,008.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-415,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,510.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-416,CHOLECYSTECTOMY EXCEPT BY LAPAROSCOPE WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,755.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-417,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,776.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-418,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,009.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-419,LAPAROSCOPIC CHOLECYSTECTOMY WITHOUT C.D.E. WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,043.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-420,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","56,225.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-421,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,542.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-422,HEPATOBILIARY DIAGNOSTIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,222.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-423,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","66,864.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-424,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,505.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-425,OTHER HEPATOBILIARY OR PANCREAS O.R. PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,692.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-432,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,113.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-433,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,456.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-434,CIRRHOSIS AND ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,913.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-435,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,044.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-436,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,923.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-437,MALIGNANCY OF HEPATOBILIARY SYSTEM OR PANCREAS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,312.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-438,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,540.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-439,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,510.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-440,DISORDERS OF PANCREAS EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,694.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-441,DISORDERS OF LIVER EXCEPT MALIGNANCY- CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,139.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-442,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,905.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-443,DISORDERS OF LIVER EXCEPT MALIGNANCY - CIRRHOSIS OR ALCOHOLIC HEPATITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,604.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-444,DISORDERS OF THE BILIARY TRACT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,700.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-445,DISORDERS OF THE BILIARY TRACT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,228.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-446,DISORDERS OF THE BILIARY TRACT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,059.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-453,COMBINED ANTERIOR/POSTERIOR SPINAL FUSION W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","147,097.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-454,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","97,569.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-455,COMBINED ANTERIOR AND POSTERIOR SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","76,656.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-456,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","137,569.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-457,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","104,032.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-458,SPINAL FUSION EXCEPT CERVICAL WITH SPINAL CURVATURE- MALIGNANCY- INFECTION OR EXTENSIVE FUSIONS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,278.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-459,SPINAL FUSION EXCEPT CERVICAL WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","107,708.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-460,SPINAL FUSION EXCEPT CERVICAL WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","62,923.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-461,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","97,219.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-462,BILATERAL OR MULTIPLE MAJOR JOINT PROCEDURES OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,307.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-463,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,846.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-464,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,592.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-465,WOUND DEBRIDEMENT AND SKIN GRAFT EXCEPT HAND FOR MUSCULOSKELETAL AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,497.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-466,REVISION OF HIP OR KNEE REPLACEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","85,520.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-467,REVISION OF HIP OR KNEE REPLACEMENT W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,219.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-468,REVISION OF HIP OR KNEE REPLACEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,864.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-469,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITH MCC OR TOTAL ANKLE REPLACEMENT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","49,350.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-470,MAJOR HIP AND KNEE JOINT REPLACEMENT OR REATTACHMENT OF LOWER EXTREMITY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,398.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-471,CERVICAL SPINAL FUSION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,268.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-472,CERVICAL SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,851.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-473,CERVICAL SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,643.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-474,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","65,164.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-475,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,097.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-476,AMPUTATION FOR MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,556.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-477,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","53,710.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-478,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,710.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-479,BIOPSIES OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,948.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-480,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,392.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-481,HIP AND FEMUR PROCEDURES EXCEPT MAJOR JOINT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,528.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-482,HIP & FEMUR PROCEDURES EXCEPT MAJOR JOINT W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,348.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-483,MAJOR JOINT & LIMB REATTACHMENT PROC OF UPPER EXTREMITY W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,180.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-485,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","54,521.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-486,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,374.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-487,KNEE PROCEDURES WITH PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,244.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-488,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,593.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-489,KNEE PROCEDURES WITHOUT PRINCIPAL DIAGNOSIS OF INFECTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,771.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-492,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","55,491.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-493,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,203.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-494,LOWER EXTREMITY AND HUMERUS PROCEDURES EXCEPT HIP- FOOT AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,630.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-495,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","58,147.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-496,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,769.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-497,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES EXCEPT HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,339.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-498,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","41,348.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-499,LOCAL EXCISION AND REMOVAL OF INTERNAL FIXATION DEVICES OF HIP AND FEMUR WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,179.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-500,SOFT TISSUE PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,462.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-501,SOFT TISSUE PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,920.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-502,SOFT TISSUE PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,292.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-503,FOOT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,059.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-504,FOOT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,382.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-505,FOOT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,382.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-506,MAJOR THUMB OR JOINT PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,611.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-507,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,356.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-508,MAJOR SHOULDER OR ELBOW JOINT PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,624.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-509,ARTHROSCOPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,780.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-510,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,691.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-511,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,496.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-512,SHOULDER- ELBOW OR FOREARM PROCEDURES- EXCEPT MAJOR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,899.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-513,HAND OR WRIST PROCEDURES- EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,944.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-514,HAND OR WRIST PROCEDURES - EXCEPT MAJOR THUMB OR JOINT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,907.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-515,OTHER MUSCULOSKELET SYS & CONN TISS O.R. PROC W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,192.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-516,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,377.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-517,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,347.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-518,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH MCC OR DISC DEVICE OR NEUROSTIMULATOR,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,348.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-519,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,323.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-520,BACK AND NECK PROCEDURES EXCEPT SPINAL FUSION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,678.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-521,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","49,014.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-522,HIP REPLACEMENT WITH PRINCIPAL DIAGNOSIS OF HIP FRACTURE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,025.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-533,FRACTURES OF FEMUR WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,601.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-534,FRACTURES OF FEMUR WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,617.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-535,FRACTURES OF HIP AND PELVIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,740.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-536,FRACTURES OF HIP AND PELVIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,345.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-537,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,931.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-538,SPRAINS- STRAINS- AND DISLOCATIONS OF HIP- PELVIS AND THIGH WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,542.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-539,OSTEOMYELITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,059.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-540,OSTEOMYELITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,724.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-541,OSTEOMYELITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,449.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-542,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,884.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-543,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,692.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-544,PATHOLOGICAL FRACTURES AND MUSCULOSKELETAL AND CONNECTIVE TISSUE MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,419.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-545,CONNECTIVE TISSUE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,992.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-546,CONNECTIVE TISSUE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,305.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-547,CONNECTIVE TISSUE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,328.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-548,SEPTIC ARTHRITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,473.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-549,SEPTIC ARTHRITIS W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,950.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-550,SEPTIC ARTHRITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,123.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-551,MEDICAL BACK PROBLEMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,969.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-552,MEDICAL BACK PROBLEMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,072.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-553,BONE DISEASES AND ARTHROPATHIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,292.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-554,BONE DISEASES AND ARTHROPATHIES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,646.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-555,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,804.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-556,SIGNS AND SYMPTOMS OF MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,900.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-557,TENDONITIS - MYOSITIS AND BURSITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,302.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-558,TENDONITIS- MYOSITIS AND BURSITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,732.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-559,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,886.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-560,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,222.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-561,AFTERCARE- MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,657.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-562,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,528.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-563,FRACTURE- SPRAIN- STRAIN AND DISLOCATION EXCEPT FEMUR- HIP- PELVIS AND THIGH WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,932.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-564,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,220.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-565,OTHER MUSCULOSKELETAL SYS & CONNECTIVE TISSUE DIAGNOSES W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,100.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-566,OTHER MUSCULOSKELETAL SYSTEM AND CONNECTIVE TISSUE DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,024.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-570,SKIN DEBRIDEMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","45,380.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-571,SKIN DEBRIDEMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,124.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-572,SKIN DEBRIDEMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,641.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-573,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","88,596.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-574,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,944.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-575,SKIN GRAFT FOR SKIN ULCER OR CELLULITIS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,184.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-576,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,961.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-577,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,758.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-578,SKIN GRAFT EXCEPT FOR SKIN ULCER OR CELLULITIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,515.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-579,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,844.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-580,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,649.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-581,OTHER SKIN- SUBCUTANEOUS TISSUE AND BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,158.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-582,MASTECTOMY FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,265.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-583,MASTECTOMY FOR MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,665.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-584,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,284.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-585,BREAST BIOPSY- LOCAL EXCISION AND OTHER BREAST PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,876.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-592,SKIN ULCERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,987.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-593,SKIN ULCERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,188.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-594,SKIN ULCERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,099.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-595,MAJOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,193.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-596,MAJOR SKIN DISORDERS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,827.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-597,MALIGNANT BREAST DISORDERS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,187.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-598,MALIGNANT BREAST DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,779.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-599,MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,739.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-600,NON-MALIGNANT BREAST DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,931.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-601,NON-MALIGNANT BREAST DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,001.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-602,CELLULITIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,985.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-603,CELLULITIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,516.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-604,TRAUMA TO THE SKIN - SUBCUTANEOUS TISSUE AND BREAST WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,860.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-605,TRAUMA TO THE SKIN- SUBCUTANEOUS TISSUE AND BREAST WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,547.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-606,MINOR SKIN DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,176.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-607,MINOR SKIN DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,209.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-614,ADRENAL AND PITUITARY PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,188.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-615,ADRENAL & PITUITARY PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,185.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-616,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,820.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-617,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,545.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-618,AMPUTATION OF LOWER LIMB FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,848.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-619,O.R. PROCEDURES FOR OBESITY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,977.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-620,O.R. PROCEDURES FOR OBESITY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,177.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-621,O.R. PROCEDURES FOR OBESITY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,542.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-622,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","57,804.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-623,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE - NUTRITIONAL AND METABOLIC DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,966.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-624,SKIN GRAFTS AND WOUND DEBRIDEMENT FOR ENDOCRINE- NUTRITIONAL AND METABOLIC DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,508.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-625,THYROID- PARATHYROID AND THYROGLOSSAL PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","45,459.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-626,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,436.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-627,THYROID - PARATHYROID AND THYROGLOSSAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,908.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-628,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,169.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-629,OTHER ENDOCRINE- NUTRITIONAL AND METABOLIC O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,548.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-630,OTHER ENDOCRINE - NUTRIT & METAB O.R. PROC W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,510.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-637,DIABETES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,995.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-638,DIABETES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,070.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-639,DIABETES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,748.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-640,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,644.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-641,MISCELLANEOUS DISORDERS OF NUTRITION- METABOLISM- FLUIDS AND ELECTROLYTES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,048.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-642,INBORN AND OTHER DISORDERS OF METABOLISM,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,600.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-643,ENDOCRINE DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,612.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-644,ENDOCRINE DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,292.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-645,ENDOCRINE DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,284.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-650,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,209.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-651,KIDNEY TRANSPLANT WITH HEMODIALYSIS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,097.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-652,KIDNEY TRANSPLANT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","50,910.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-653,MAJOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","87,187.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-654,MAJOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,403.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-655,MAJOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,281.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-656,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,507.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-657,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,945.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-658,KIDNEY AND URETER PROCEDURES FOR NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,265.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-659,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,636.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-660,KIDNEY & URETER PROCEDURES FOR NON-NEOPLASM W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,094.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-661,KIDNEY AND URETER PROCEDURES FOR NON-NEOPLASM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,030.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-662,MINOR BLADDER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","46,876.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-663,MINOR BLADDER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,518.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-664,MINOR BLADDER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,947.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-665,PROSTATECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,587.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-666,PROSTATECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,748.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-667,PROSTATECTOMY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,918.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-668,TRANSURETHRAL PROCEDURES W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","44,081.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-669,TRANSURETHRAL PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,510.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-670,TRANSURETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,624.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-671,URETHRAL PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,427.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-672,URETHRAL PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,414.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-673,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","55,409.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-674,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","38,086.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-675,OTHER KIDNEY AND URINARY TRACT PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,032.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-682,RENAL FAILURE WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,523.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-683,RENAL FAILURE WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,049.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-684,RENAL FAILURE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,720.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-686,KIDNEY AND URINARY TRACT NEOPLASMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,971.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-687,KIDNEY AND URINARY TRACT NEOPLASMS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,764.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-688,KIDNEY AND URINARY TRACT NEOPLASMS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,964.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-689,KIDNEY AND URINARY TRACT INFECTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,780.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-690,KIDNEY AND URINARY TRACT INFECTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,675.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-693,URINARY STONES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,300.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-694,URINARY STONES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,668.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-695,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,180.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-696,KIDNEY AND URINARY TRACT SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,035.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-697,URETHRAL STRICTURE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,952.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-698,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,707.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-699,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,403.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-700,OTHER KIDNEY AND URINARY TRACT DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,916.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-707,MAJOR MALE PELVIC PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,729.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-708,MAJOR MALE PELVIC PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,862.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-709,PENIS PROCEDURES W CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,990.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-710,PENIS PROCEDURES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,598.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-711,TESTES PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,084.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-712,TESTES PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,920.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-713,TRANSURETHRAL PROSTATECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,865.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-714,TRANSURETHRAL PROSTATECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,856.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-715,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,302.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-716,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES FOR MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,424.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-717,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,776.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-718,OTHER MALE REPRODUCTIVE SYSTEM O.R. PROCEDURES EXCEPT MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,779.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-722,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,344.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-723,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,425.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-724,MALIGNANCY- MALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,390.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-725,BENIGN PROSTATIC HYPERTROPHY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,510.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-726,BENIGN PROSTATIC HYPERTROPHY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,892.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-727,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,689.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-728,INFLAMMATION OF THE MALE REPRODUCTIVE SYSTEM WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,856.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-729,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,076.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-730,OTHER MALE REPRODUCTIVE SYSTEM DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,051.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-734,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,564.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-735,PELVIC EVISCERATION - RADICAL HYSTERECTOMY AND RADICAL VULVECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,616.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-736,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,131.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-737,UTERINE AND ADNEXA PROCEDURES FOR OVARIAN OR ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,931.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-738,UTERINE & ADNEXA PROC FOR OVARIAN OR ADNEXAL MALIGNANCY W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,625.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-739,UTERINE -ADNEXA PROC FOR NON-OVARIAN/ADNEXAL MALIG W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,147.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-740,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,800.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-741,UTERINE AND ADNEXA PROCEDURES FOR NON-OVARIAN AND NON-ADNEXAL MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,472.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-742,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,472.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-743,UTERINE AND ADNEXA PROCEDURES FOR NON-MALIGNANCY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,116.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-744,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,704.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-745,D&C- CONIZATION- LAPAROSCOPY AND TUBAL INTERRUPTION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,728.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-746,VAGINA - CERVIX AND VULVA PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,750.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-747,VAGINA- CERVIX AND VULVA PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,008.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-748,FEMALE REPRODUCTIVE SYSTEM RECONSTRUCTIVE PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,572.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-749,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,318.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-750,OTHER FEMALE REPRODUCTIVE SYSTEM O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,454.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-754,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,136.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-755,MALIGNANCY- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,041.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-756,MALIGNANCY - FEMALE REPRODUCTIVE SYSTEM W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,657.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-757,INFECTIONS - FEMALE REPRODUCTIVE SYSTEM W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,353.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-758,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,472.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-759,INFECTIONS- FEMALE REPRODUCTIVE SYSTEM WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,931.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-760,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,761.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-761,MENSTRUAL AND OTHER FEMALE REPRODUCTIVE SYSTEM DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","9,440.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-768,VAGINAL DELIVERY W O.R. PROC EXCEPT STERIL &/OR D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,732.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-769,POSTPARTUM AND POST ABORTION DIAGNOSES WITH O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,926.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-770,ABORTION WITH D&C- ASPIRATION CURETTAGE OR HYSTEROTOMY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,209.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-776,POSTPARTUM AND POST ABORTION DIAGNOSES WITHOUT O.R. PROCEDURES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,300.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-779,ABORTION WITHOUT D&C,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,646.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-783,CESAREAN SECTION WITH STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,963.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-784,CESAREAN SECTION WITH STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,518.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-785,CESAREAN SECTION WITH STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,644.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-786,CESAREAN SECTION WITHOUT STERILIZATION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,457.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-787,CESAREAN SECTION WITHOUT STERILIZATION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,003.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-788,CESAREAN SECTION WITHOUT STERILIZATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,193.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-789,NEONATES- DIED OR TRANSFERRED TO ANOTHER ACUTE CARE FACILITY,Acute Care,Per Diem,"$5,358.42 ",IP,600,"27,496.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-790,EXTREME IMMATURITY OR RESPIRATORY DISTRESS SYNDROME- NEONATE,Acute Care,Per Diem,"$5,358.42 ",IP,600,"90,673.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-791,PREMATURITY W MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"61,926.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-792,PREMATURITY W/O MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"37,364.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-793,FULL TERM NEONATE WITH MAJOR PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"63,611.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-794,NEONATE WITH OTHER SIGNIFICANT PROBLEMS,Acute Care,Per Diem,"$5,358.42 ",IP,600,"22,515.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-795,NORMAL NEWBORN,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-796,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,086.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-797,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,718.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-798,VAGINAL DELIVERY WITH STERILIZATION AND/OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,236.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-799,SPLENECTOMY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","82,302.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-800,SPLENECTOMY WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,222.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-801,SPLENECTOMY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,936.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-802,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,339.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-803,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,156.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-804,OTHER O.R. PROCEDURES OF THE BLOOD AND BLOOD FORMING ORGANS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,827.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-805,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,428.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-806,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,742.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-807,VAGINAL DELIVERY WITHOUT STERILIZATION OR D&C WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,257.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-808,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,846.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-809,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,547.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-810,MAJOR HEMATOLOGICAL AND IMMUNOLOGICAL DIAGNOSES EXCEPT SICKLE CELL CRISIS AND COAGULATION DISORDERS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,371.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-811,RED BLOOD CELL DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,041.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-812,RED BLOOD CELL DISORDERS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,075.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-813,COAGULATION DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","24,715.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-814,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,251.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-815,RETICULOENDOTHELIAL AND IMMUNITY DISORDERS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,880.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-816,RETICULOENDOTHELIAL & IMMUNITY DISORDERS W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,574.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-817,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,828.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-818,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,064.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-819,OTHER ANTEPARTUM DIAGNOSES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,966.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-820,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","90,996.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-821,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","34,481.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-822,LYMPHOMA AND LEUKEMIA WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,025.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-823,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","71,953.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-824,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","37,803.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-825,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","22,411.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-826,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","80,588.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-827,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,961.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-828,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,843.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-829,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,291.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-830,MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASMS WITH OTHER PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,624.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-831,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,937.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-832,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,476.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-833,OTHER ANTEPARTUM DIAGNOSES WITHOUT O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,576.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-834,ACUTE LEUKEMIA W/O MAJOR O.R. PROCEDURE W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","96,801.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-835,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,819.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-836,ACUTE LEUKEMIA WITHOUT MAJOR O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,713.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-837,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS OR WITH HIGH DOSE CHEMOTHERAPY AGENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","91,185.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-838,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC OR HIGH DOSE CHEMOTHERAPY AGENT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,140.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-839,CHEMOTHERAPY WITH ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,780.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-840,LYMPHOMA AND NON-ACUTE LEUKEMIA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","51,451.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-841,LYMPHOMA & NON-ACUTE LEUKEMIA W CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,932.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-842,LYMPHOMA AND NON-ACUTE LEUKEMIA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,524.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-843,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,446.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-844,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,888.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-845,OTHER MYELOPROLIFERATIVE DISORDERS OR POORLY DIFFERENTIATED NEOPLASTIC DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,558.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-846,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,718.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-847,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,363.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-848,CHEMOTHERAPY WITHOUT ACUTE LEUKEMIA AS SECONDARY DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,464.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-849,RADIOTHERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","39,800.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-853,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","79,113.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-854,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","33,510.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-855,INFECTIOUS AND PARASITIC DISEASES WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,920.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-856,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","72,731.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-857,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,555.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-858,POSTOPERATIVE OR POST-TRAUMATIC INFECTIONS WITH O.R. PROCEDURES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,574.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-862,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,060.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-863,POSTOPERATIVE & POST-TRAUMATIC INFECTIONS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,638.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-864,FEVER AND INFLAMMATORY CONDITIONS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,000.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-865,VIRAL ILLNESS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,662.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-866,VIRAL ILLNESS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,395.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-867,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,672.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-868,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,934.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-869,OTHER INFECTIOUS AND PARASITIC DISEASES DIAGNOSES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,616.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-870,SEPTICEMIA OR SEVERE SEPSIS WITH MV >96 HOURS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","102,796.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-871,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,891.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-872,SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,345.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-876,O.R. PROCEDURES WITH PRINCIPAL DIAGNOSIS OF MENTAL ILLNESS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,180.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-880,ACUTE ADJUSTMENT REACTION AND PSYCHOSOCIAL DYSFUNCTION,Acute Care,Per Diem,"$5,358.42 ",IP,550,"13,817.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-881,DEPRESSIVE NEUROSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"12,822.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-882,NEUROSES EXCEPT DEPRESSIVE,Acute Care,Per Diem,"$5,358.42 ",IP,550,"13,168.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-883,DISORDERS OF PERSONALITY & IMPULSE CONTROL,Acute Care,Per Diem,"$5,358.42 ",IP,550,"25,252.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-884,ORGANIC DISTURBANCES AND INTELLECTUAL DISABILITY,Acute Care,Per Diem,"$5,358.42 ",IP,550,"23,100.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-885,PSYCHOSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"19,793.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-886,BEHAVIORAL AND DEVELOPMENTAL DISORDERS,Acute Care,Per Diem,"$5,358.42 ",IP,550,"19,544.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-887,OTHER MENTAL DISORDER DIAGNOSES,Acute Care,Per Diem,"$5,358.42 ",IP,550,"17,259.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-894,ALCOHOL- DRUG ABUSE OR DEPENDENCE- LEFT AMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,760.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-895,ALCOHOL- DRUG ABUSE OR DEPENDENCE WITH REHABILITATION THERAPY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,472.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-896,ALCOHOL - DRUG ABUSE OR DEPENDENCE WITHOUT REHABILITATION THERAPY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,432.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-897,ALCOHOL/DRUG ABUSE OR DEPENDENCE W/O REHABILITATION THERAPY W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","13,208.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-901,WOUND DEBRIDEMENTS FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","68,195.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-902,WOUND DEBRIDEMENTS FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,398.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-903,WOUND DEBRIDEMENTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,150.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-904,SKIN GRAFTS FOR INJURIES WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","59,542.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-905,SKIN GRAFTS FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,345.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-906,HAND PROCEDURES FOR INJURIES,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","28,700.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-907,OTHER O.R. PROCEDURES FOR INJURIES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","63,313.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-908,OTHER O.R. PROCEDURES FOR INJURIES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","32,646.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-909,OTHER O.R. PROCEDURES FOR INJURIES WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,993.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-913,TRAUMATIC INJURY WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,182.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-914,TRAUMATIC INJURY WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,217.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-915,ALLERGIC REACTIONS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","27,161.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-916,ALLERGIC REACTIONS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","10,516.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-917,POISONING & TOXIC EFFECTS OF DRUGS W MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,640.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-918,POISONING & TOXIC EFFECTS OF DRUGS W/O MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,657.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-919,COMPLICATIONS OF TREATMENT WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","29,350.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-920,COMPLICATIONS OF TREATMENT WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","16,436.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-921,COMPLICATIONS OF TREATMENT WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,062.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-922,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","25,401.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-923,OTHER INJURY- POISONING AND TOXIC EFFECT DIAGNOSES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,886.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-927,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITH SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","336,494.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-928,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","104,419.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-929,FULL THICKNESS BURN WITH SKIN GRAFT OR INHALATION INJURY WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","48,142.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-933,EXTENSIVE BURNS OR FULL THICKNESS BURNS WITH MV >96 HOURS WITHOUT SKIN GRAFT,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","36,121.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-934,FULL THICKNESS BURN WITHOUT SKIN GRAFT OR INHALATION INJURY,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","31,044.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-935,NON-EXTENSIVE BURNS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,932.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-939,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","54,179.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-940,O.R. PROCEDURES WITH DIAGNOSES OF OTHER CONTACT WITH HEALTH SERVICES WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","35,481.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-941,O.R. PROC W DIAGNOSES OF OTHER CONTACT W HEALTH SERVICES W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","30,795.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-945,REHABILITATION WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,755.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-946,REHABILITATION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","18,035.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-947,SIGNS AND SYMPTOMS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","19,041.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-948,SIGNS AND SYMPTOMS WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","12,569.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-949,AFTERCARE WITH CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,713.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-950,AFTERCARE WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","11,822.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-951,OTHER FACTORS INFLUENCING HEALTH STATUS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","8,931.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-955,CRANIOTOMY FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","100,608.00",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-956,LIMB REATTACHMENT- HIP AND FEMUR PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","61,580.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-957,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","118,732.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-958,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","67,286.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-959,OTHER O.R. PROCEDURES FOR MULTIPLE SIGNIFICANT TRAUMA WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,747.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-963,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","43,587.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-964,OTHER MULTIPLE SIGNIFICANT TRAUMA WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","23,814.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-965,OTHER MULTIPLE SIGNIFICANT TRAUMA W/O CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","14,606.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-969,HIV WITH EXTENSIVE O.R. PROCEDURES WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","92,598.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-970,HIV WITH EXTENSIVE O.R. PROCEDURES WITHOUT MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","47,121.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-974,HIV WITH MAJOR RELATED CONDITION WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","42,971.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-975,HIV WITH MAJOR RELATED CONDITION WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","20,465.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-976,HIV WITH MAJOR RELATED CONDITION WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","15,185.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-977,HIV WITH OR WITHOUT OTHER RELATED CONDITION,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","21,132.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-981,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","73,724.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-982,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","40,659.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-983,EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,476.80",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-987,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","52,193.60",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-988,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITH CC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","26,891.20",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-989,NON-EXTENSIVE O.R. PROCEDURES UNRELATED TO PRINCIPAL DIAGNOSIS WITHOUT CC/MCC,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","17,854.40",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-998,PRINCIPAL DIAGNOSIS INVALID AS DISCHARGE DIAGNOSIS,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
United Healthcare VA PC3,DRG,MS-999,UNGROUPABLE,Acute Care,Per Diem,"$5,358.42 ",IP,"1,275.00","5,358.42",,,,,,,,,,,,
United Healthcare VA PC3,ExceptPatType,14,,Swing Bed,Per Diem,"$4,816.25 ",IP,640,"4,816.25",,,,,,,,,,,,
United Healthcare VA PC3,CPT,36415,Routine venipuncture,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,78267,Breath tst attain/anal c-14,Lab Services,Per Unit,$11.06 ,OP,11.06,11.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,78268,Breath test analysis c-14,Lab Services,Per Unit,$94.41 ,OP,94.41,94.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80047,Metabolic panel ionized ca,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80048,Metabolic panel total ca,Lab Services,Per Unit,$8.46 ,OP,8.46,8.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80051,Electrolyte panel,Lab Services,Per Unit,$7.01 ,OP,7.01,7.01,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80053,Comprehen metabolic panel,Lab Services,Per Unit,$10.56 ,OP,10.56,10.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80055,Obstetric panel,Lab Services,Per Unit,$47.81 ,OP,47.81,47.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80061,Lipid panel,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80069,Renal function panel,Lab Services,Per Unit,$8.68 ,OP,8.68,8.68,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80074,Acute hepatitis panel,Lab Services,Per Unit,$47.63 ,OP,47.63,47.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80076,Hepatic function panel,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80081,Obstetric panel,Lab Services,Per Unit,$74.86 ,OP,74.86,74.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80143,Drug assay acetaminophen,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80145,Drug assay adalimumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80150,Assay of amikacin,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80151,Drug assay amiodarone,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80155,Drug assay caffeine,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80156,Assay carbamazepine total,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80157,Assay carbamazepine free,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80158,Drug assay cyclosporine,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80159,Drug assay clozapine,Lab Services,Per Unit,$20.15 ,OP,20.15,20.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80161,Asy carbamazepin 10-11-epxid,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80162,Assay of digoxin total,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80163,Assay of digoxin free,Lab Services,Per Unit,$13.28 ,OP,13.28,13.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80164,Assay dipropylacetic acd tot,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80165,Dipropylacetic acid free,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80167,Drug assay felbamate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80168,Assay of ethosuximide,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80169,Drug assay everolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80170,Assay of gentamicin,Lab Services,Per Unit,$16.38 ,OP,16.38,16.38,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80171,Drug screen quant gabapentin,Lab Services,Per Unit,$21.67 ,OP,21.67,21.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80173,Assay of haloperidol,Lab Services,Per Unit,$15.78 ,OP,15.78,15.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80175,Drug screen quan lamotrigine,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80176,Assay of lidocaine,Lab Services,Per Unit,$14.69 ,OP,14.69,14.69,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80177,Drug scrn quan levetiracetam,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80178,Assay of lithium,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80179,Drug assay salicylate,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80180,Drug scrn quan mycophenolate,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80181,Drug assay flecainide,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80183,Drug scrn quant oxcarbazepin,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80184,Assay of phenobarbital,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80185,Assay of phenytoin total,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80186,Assay of phenytoin free,Lab Services,Per Unit,$13.76 ,OP,13.76,13.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80187,Drug assay posaconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80188,Assay of primidone,Lab Services,Per Unit,$16.59 ,OP,16.59,16.59,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80189,Drug assay itraconzaole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80190,Assay of procainamide,Lab Services,Per Unit,$60.00 ,OP,60,60,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80192,Assay of procainamide,Lab Services,Per Unit,$16.75 ,OP,16.75,16.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80193,Drug assay leflunomide,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80194,Assay of quinidine,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80195,Assay of sirolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80197,Assay of tacrolimus,Lab Services,Per Unit,$13.73 ,OP,13.73,13.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80198,Assay of theophylline,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80199,Drug screen quant tiagabine,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80200,Assay of tobramycin,Lab Services,Per Unit,$16.13 ,OP,16.13,16.13,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80201,Assay of topiramate,Lab Services,Per Unit,$11.92 ,OP,11.92,11.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80202,Assay of vancomycin,Lab Services,Per Unit,$13.54 ,OP,13.54,13.54,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80203,Drug screen quant zonisamide,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80204,Drug assay methotrexate,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80210,Drug assay rufinamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80230,Drug assay infliximab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80235,Drug assay lacosamide,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80280,Drug assay vedolizumab,Lab Services,Per Unit,$38.57 ,OP,38.57,38.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80285,Drug assay voriconazole,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80299,Quantitative assay drug,Lab Services,Per Unit,$18.64 ,OP,18.64,18.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80305,Drug test prsmv dir opt obs,Lab Services,Per Unit,$12.60 ,OP,12.6,12.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80306,Drug test prsmv instrmnt,Lab Services,Per Unit,$17.14 ,OP,17.14,17.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80307,Drug test prsmv chem anlyzr,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80400,Acth stimulation panel,Lab Services,Per Unit,$32.62 ,OP,32.62,32.62,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80402,Acth stimulation panel,Lab Services,Per Unit,$86.96 ,OP,86.96,86.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80406,Acth stimulation panel,Lab Services,Per Unit,$78.26 ,OP,78.26,78.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80408,Aldosterone suppression eval,Lab Services,Per Unit,$125.50 ,OP,125.5,125.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80410,Calcitonin stimul panel,Lab Services,Per Unit,$80.37 ,OP,80.37,80.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80412,Crh stimulation panel,Lab Services,Per Unit,$801.62 ,OP,801.62,801.62,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80414,Testosterone response panel,Lab Services,Per Unit,$51.64 ,OP,51.64,51.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80415,Tot estradiol response panel,Lab Services,Per Unit,$55.89 ,OP,55.89,55.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80416,Renin stimulation panel,Lab Services,Per Unit,$209.32 ,OP,209.32,209.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80417,Renin stimulation panel,Lab Services,Per Unit,$43.99 ,OP,43.99,43.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80418,Pituitary evaluation panel,Lab Services,Per Unit,$579.48 ,OP,579.48,579.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80420,Dexamethasone panel,Lab Services,Per Unit,$161.88 ,OP,161.88,161.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80422,Glucagon tolerance panel,Lab Services,Per Unit,$46.07 ,OP,46.07,46.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80424,Glucagon tolerance panel,Lab Services,Per Unit,$50.50 ,OP,50.5,50.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80426,Gonadotropin hormone panel,Lab Services,Per Unit,$148.41 ,OP,148.41,148.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80428,Growth hormone panel,Lab Services,Per Unit,$66.70 ,OP,66.7,66.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80430,Growth hormone panel,Lab Services,Per Unit,$129.33 ,OP,129.33,129.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80432,Insulin suppression panel,Lab Services,Per Unit,$165.61 ,OP,165.61,165.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80434,Insulin tolerance panel,Lab Services,Per Unit,$285.03 ,OP,285.03,285.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80435,Insulin tolerance panel,Lab Services,Per Unit,$103.00 ,OP,103,103,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80436,Metyrapone panel,Lab Services,Per Unit,$91.16 ,OP,91.16,91.16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80438,Trh stimulation panel,Lab Services,Per Unit,$50.41 ,OP,50.41,50.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,80439,Trh stimulation panel,Lab Services,Per Unit,$67.21 ,OP,67.21,67.21,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81000,Urinalysis nonauto w/scope,Lab Services,Per Unit,$4.02 ,OP,4.02,4.02,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81001,Urinalysis auto w/scope,Lab Services,Per Unit,$3.17 ,OP,3.17,3.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81002,Urinalysis nonauto w/o scope,Lab Services,Per Unit,$3.48 ,OP,3.48,3.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81003,Urinalysis auto w/o scope,Lab Services,Per Unit,$2.25 ,OP,2.25,2.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81005,Urinalysis,Lab Services,Per Unit,$2.17 ,OP,2.17,2.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81007,Urine screen for bacteria,Lab Services,Per Unit,$29.98 ,OP,29.98,29.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81015,Microscopic exam of urine,Lab Services,Per Unit,$3.05 ,OP,3.05,3.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81020,Urinalysis glass test,Lab Services,Per Unit,$4.70 ,OP,4.7,4.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81025,Urine pregnancy test,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81050,Urinalysis volume measure,Lab Services,Per Unit,$3.64 ,OP,3.64,3.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81105,Hpa-1 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81106,Hpa-2 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81107,Hpa-3 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81108,Hpa-4 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81109,Hpa-5 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81110,Hpa-6 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81111,Hpa-9 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81112,Hpa-15 genotyping,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81120,Idh1 common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81121,Idh2 common variants,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81161,Dmd dup/delet analysis,Lab Services,Per Unit,$279.00 ,OP,279,279,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81162,Brca1&2 gen full seq dup/del,Lab Services,Per Unit,"$1,824.88 ",OP,"1,824.88","1,824.88",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81163,Brca1&2 gene full seq alys,Lab Services,Per Unit,$468.00 ,OP,468,468,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81164,Brca1&2 gen ful dup/del alys,Lab Services,Per Unit,$584.23 ,OP,584.23,584.23,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81165,Brca1 gene full seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81166,Brca1 gene full dup/del alys,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81167,Brca2 gene full dup/del alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81168,Ccnd1/igh translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81170,Abl1 gene,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81171,Aff2 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81172,Aff2 gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81173,Ar gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81174,Ar gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81175,Asxl1 full gene sequence,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81176,Asxl1 gene target seq alys,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81177,Atn1 gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81178,Atxn1 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81179,Atxn2 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81180,Atxn3 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81181,Atxn7 gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81182,Atxn8os gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81183,Atxn10 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81184,Cacna1a gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81185,Cacna1a gene full gene seq,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81186,Cacna1a gen known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81187,Cnbp gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81188,Cstb gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81189,Cstb gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81190,Cstb gene known famil vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81191,Ntrk1 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81192,Ntrk2 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81193,Ntrk3 translocation analysis,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81194,Ntrk translocation analysis,Lab Services,Per Unit,$518.28 ,OP,518.28,518.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81200,Aspa gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81201,Apc gene full sequence,Lab Services,Per Unit,$780.00 ,OP,780,780,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81202,Apc gene known fam variants,Lab Services,Per Unit,$280.00 ,OP,280,280,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81203,Apc gene dup/delet variants,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81204,Ar gene charac alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81205,Bckdhb gene,Lab Services,Per Unit,$94.99 ,OP,94.99,94.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81206,Bcr/abl1 gene major bp,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81207,Bcr/abl1 gene minor bp,Lab Services,Per Unit,$144.84 ,OP,144.84,144.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81208,Bcr/abl1 gene other bp,Lab Services,Per Unit,$214.62 ,OP,214.62,214.62,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81209,Blm gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81210,Braf gene,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81212,Brca1&2 185&5385&6174 vrnt,Lab Services,Per Unit,$440.00 ,OP,440,440,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81215,Brca1 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81216,Brca2 gene full seq alys,Lab Services,Per Unit,$185.12 ,OP,185.12,185.12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81217,Brca2 gene known famil vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81218,Cebpa gene full sequence,Lab Services,Per Unit,$241.90 ,OP,241.9,241.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81219,Calr gene com variants,Lab Services,Per Unit,$121.63 ,OP,121.63,121.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81220,Cftr gene com variants,Lab Services,Per Unit,$556.60 ,OP,556.6,556.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81221,Cftr gene known fam variants,Lab Services,Per Unit,$97.22 ,OP,97.22,97.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81222,Cftr gene dup/delet variants,Lab Services,Per Unit,$435.07 ,OP,435.07,435.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81223,Cftr gene full sequence,Lab Services,Per Unit,$499.00 ,OP,499,499,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81224,Cftr gene intron poly t,Lab Services,Per Unit,$168.75 ,OP,168.75,168.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81225,Cyp2c19 gene com variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81226,Cyp2d6 gene com variants,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81227,Cyp2c9 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81228,Cytogen micrarray copy nmbr,Lab Services,Per Unit,$900.00 ,OP,900,900,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81229,Cytogen m array copy no&snp,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81230,Cyp3a4 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81231,Cyp3a5 gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81232,Dpyd gene common variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81233,Btk gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81234,Dmpk gene detc abnor allele,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81235,Egfr gene com variants,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81236,Ezh2 gene full gene sequence,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81237,Ezh2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81238,F9 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81239,Dmpk gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81240,F2 gene,Lab Services,Per Unit,$65.69 ,OP,65.69,65.69,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81241,F5 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81242,Fancc gene,Lab Services,Per Unit,$36.62 ,OP,36.62,36.62,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81243,Fmr1 gene detection,Lab Services,Per Unit,$57.04 ,OP,57.04,57.04,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81244,Fmr1 gene charac alleles,Lab Services,Per Unit,$44.89 ,OP,44.89,44.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81245,Flt3 gene,Lab Services,Per Unit,$165.51 ,OP,165.51,165.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81246,Flt3 gene analysis,Lab Services,Per Unit,$83.00 ,OP,83,83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81247,G6pd gene alys cmn variant,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81248,G6pd known familial variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81249,G6pd full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81250,G6pc gene,Lab Services,Per Unit,$58.49 ,OP,58.49,58.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81251,Gba gene,Lab Services,Per Unit,$47.25 ,OP,47.25,47.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81252,Gjb2 gene full sequence,Lab Services,Per Unit,$101.12 ,OP,101.12,101.12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81253,Gjb2 gene known fam variants,Lab Services,Per Unit,$61.52 ,OP,61.52,61.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81254,Gjb6 gene com variants,Lab Services,Per Unit,$35.00 ,OP,35,35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81255,Hexa gene,Lab Services,Per Unit,$51.45 ,OP,51.45,51.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81256,Hfe gene,Lab Services,Per Unit,$65.36 ,OP,65.36,65.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81257,Hba1/hba2 gene,Lab Services,Per Unit,$102.26 ,OP,102.26,102.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81258,Hba1/hba2 gene fam vrnt,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81259,Hba1/hba2 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81260,Ikbkap gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81261,Igh gene rearrange amp meth,Lab Services,Per Unit,$197.99 ,OP,197.99,197.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81262,Igh gene rearrang dir probe,Lab Services,Per Unit,$68.55 ,OP,68.55,68.55,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81263,Igh vari regional mutation,Lab Services,Per Unit,$294.52 ,OP,294.52,294.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81264,Igk rearrangeabn clonal pop,Lab Services,Per Unit,$172.73 ,OP,172.73,172.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81265,Str markers specimen anal,Lab Services,Per Unit,$233.07 ,OP,233.07,233.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81266,Str markers spec anal addl,Lab Services,Per Unit,$304.81 ,OP,304.81,304.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81267,Chimerism anal no cell selec,Lab Services,Per Unit,$207.46 ,OP,207.46,207.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81268,Chimerism anal w/cell select,Lab Services,Per Unit,$260.79 ,OP,260.79,260.79,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81269,Hba1/hba2 gene dup/del vrnts,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81270,Jak2 gene,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81271,Htt gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81272,Kit gene targeted seq analys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81273,Kit gene analys d816 variant,Lab Services,Per Unit,$124.87 ,OP,124.87,124.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81274,Htt gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81275,Kras gene variants exon 2,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81276,Kras gene addl variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81277,Cytogenomic neo microra alys,Lab Services,Per Unit,"$1,160.00 ",OP,"1,160.00","1,160.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81278,Igh@/bcl2 translocation alys,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81279,Jak2 gene trgt sequence alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81283,Ifnl3 gene,Lab Services,Per Unit,$73.37 ,OP,73.37,73.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81284,Fxn gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81285,Fxn gene charac alleles,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81286,Fxn gene full gene sequence,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81287,Mgmt gene prmtr mthyltn alys,Lab Services,Per Unit,$124.64 ,OP,124.64,124.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81288,Mlh1 gene,Lab Services,Per Unit,$192.32 ,OP,192.32,192.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81289,Fxn gene known famil variant,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81290,Mcoln1 gene,Lab Services,Per Unit,$39.31 ,OP,39.31,39.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81291,Mthfr gene,Lab Services,Per Unit,$65.34 ,OP,65.34,65.34,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81292,Mlh1 gene full seq,Lab Services,Per Unit,$675.40 ,OP,675.4,675.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81293,Mlh1 gene known variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81294,Mlh1 gene dup/delete variant,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81295,Msh2 gene full seq,Lab Services,Per Unit,$381.70 ,OP,381.7,381.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81296,Msh2 gene known variants,Lab Services,Per Unit,$337.73 ,OP,337.73,337.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81297,Msh2 gene dup/delete variant,Lab Services,Per Unit,$213.30 ,OP,213.3,213.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81298,Msh6 gene full seq,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81299,Msh6 gene known variants,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81300,Msh6 gene dup/delete variant,Lab Services,Per Unit,$238.00 ,OP,238,238,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81301,Microsatellite instability,Lab Services,Per Unit,$348.56 ,OP,348.56,348.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81302,Mecp2 gene full seq,Lab Services,Per Unit,$527.87 ,OP,527.87,527.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81303,Mecp2 gene known variant,Lab Services,Per Unit,$120.00 ,OP,120,120,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81304,Mecp2 gene dup/delet variant,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81305,Myd88 gene p.leu265pro vrnt,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81306,Nudt15 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81307,Palb2 gene full gene seq,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81308,Palb2 gene known famil vrnt,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81309,Pik3ca gene trgt seq alys,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81310,Npm1 gene,Lab Services,Per Unit,$246.52 ,OP,246.52,246.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81311,Nras gene variants exon 2&3,Lab Services,Per Unit,$295.79 ,OP,295.79,295.79,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81312,Pabpn1 gene detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81313,Pca3/klk3 antigen,Lab Services,Per Unit,$255.05 ,OP,255.05,255.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81314,Pdgfra gene,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81315,Pml/raralpha com breakpoints,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81316,Pml/raralpha 1 breakpoint,Lab Services,Per Unit,$207.31 ,OP,207.31,207.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81317,Pms2 gene full seq analysis,Lab Services,Per Unit,$676.50 ,OP,676.5,676.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81318,Pms2 known familial variants,Lab Services,Per Unit,$331.00 ,OP,331,331,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81319,Pms2 gene dup/delet variants,Lab Services,Per Unit,$203.50 ,OP,203.5,203.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81320,Plcg2 gene common variants,Lab Services,Per Unit,$291.36 ,OP,291.36,291.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81321,Pten gene full sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81322,Pten gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81323,Pten gene dup/delet variant,Lab Services,Per Unit,$300.00 ,OP,300,300,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81324,Pmp22 gene dup/delet,Lab Services,Per Unit,$758.36 ,OP,758.36,758.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81325,Pmp22 gene full sequence,Lab Services,Per Unit,$769.58 ,OP,769.58,769.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81326,Pmp22 gene known fam variant,Lab Services,Per Unit,$46.60 ,OP,46.6,46.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81327,Sept9 gen prmtr mthyltn alys,Lab Services,Per Unit,$192.00 ,OP,192,192,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81328,Slco1b1 gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81329,Smn1 gene dos/deletion alys,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81330,Smpd1 gene common variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81331,Snrpn/ube3a gene,Lab Services,Per Unit,$51.07 ,OP,51.07,51.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81332,Serpina1 gene,Lab Services,Per Unit,$43.65 ,OP,43.65,43.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81333,Tgfbi gene common variants,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81334,Runx1 gene targeted seq alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81335,Tpmt gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81336,Smn1 gene full gene sequence,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81337,Smn1 gen nown famil seq vrnt,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81338,Mpl gene common variants,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81339,Mpl gene seq alys exon 10,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81340,Trb@ gene rearrange amplify,Lab Services,Per Unit,$208.92 ,OP,208.92,208.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81341,Trb@ gene rearrange dirprobe,Lab Services,Per Unit,$49.59 ,OP,49.59,49.59,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81342,Trg gene rearrangement anal,Lab Services,Per Unit,$201.50 ,OP,201.5,201.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81343,Ppp2r2b gen detc abnor allel,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81344,Tbp gene detc abnor alleles,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81345,Tert gene targeted seq alys,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81346,Tyms gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81347,Sf3b1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81348,Srsf2 gene common variants,Lab Services,Per Unit,$175.40 ,OP,175.4,175.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81350,Ugt1a1 gene common variants,Lab Services,Per Unit,$234.00 ,OP,234,234,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81351,Tp53 gene full gene sequence,Lab Services,Per Unit,$641.85 ,OP,641.85,641.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81352,Tp53 gene trgt sequence alys,Lab Services,Per Unit,$329.51 ,OP,329.51,329.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81353,Tp53 gene known famil vrnt,Lab Services,Per Unit,$308.00 ,OP,308,308,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81355,Vkorc1 gene,Lab Services,Per Unit,$88.20 ,OP,88.2,88.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81357,U2af1 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81360,Zrsr2 gene common variants,Lab Services,Per Unit,$193.25 ,OP,193.25,193.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81361,Hbb gene com variants,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81362,Hbb gene known fam variant,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81363,Hbb gene dup/del variants,Lab Services,Per Unit,$202.40 ,OP,202.4,202.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81364,Hbb full gene sequence,Lab Services,Per Unit,$324.58 ,OP,324.58,324.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81370,Hla i & ii typing lr,Lab Services,Per Unit,$402.12 ,OP,402.12,402.12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81371,Hla i & ii type verify lr,Lab Services,Per Unit,$404.52 ,OP,404.52,404.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81372,Hla i typing complete lr,Lab Services,Per Unit,$403.59 ,OP,403.59,403.59,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81373,Hla i typing 1 locus lr,Lab Services,Per Unit,$127.43 ,OP,127.43,127.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81374,Hla i typing 1 antigen lr,Lab Services,Per Unit,$74.33 ,OP,74.33,74.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81375,Hla ii typing ag equiv lr,Lab Services,Per Unit,$220.74 ,OP,220.74,220.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81376,Hla ii typing 1 locus lr,Lab Services,Per Unit,$122.22 ,OP,122.22,122.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81377,Hla ii type 1 ag equiv lr,Lab Services,Per Unit,$94.74 ,OP,94.74,94.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81378,Hla i & ii typing hr,Lab Services,Per Unit,$345.57 ,OP,345.57,345.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81379,Hla i typing complete hr,Lab Services,Per Unit,$335.38 ,OP,335.38,335.38,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81380,Hla i typing 1 locus hr,Lab Services,Per Unit,$177.25 ,OP,177.25,177.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81381,Hla i typing 1 allele hr,Lab Services,Per Unit,$169.90 ,OP,169.9,169.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81382,Hla ii typing 1 loc hr,Lab Services,Per Unit,$123.68 ,OP,123.68,123.68,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81383,Hla ii typing 1 allele hr,Lab Services,Per Unit,$109.13 ,OP,109.13,109.13,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81400,Mopath procedure level 1,Lab Services,Per Unit,$63.96 ,OP,63.96,63.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81401,Mopath procedure level 2,Lab Services,Per Unit,$137.00 ,OP,137,137,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81402,Mopath procedure level 3,Lab Services,Per Unit,$150.33 ,OP,150.33,150.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81403,Mopath procedure level 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81404,Mopath procedure level 5,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81405,Mopath procedure level 6,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81406,Mopath procedure level 7,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81407,Mopath procedure level 8,Lab Services,Per Unit,$846.27 ,OP,846.27,846.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81408,Mopath procedure level 9,Lab Services,Per Unit,"$2,000.00 ",OP,"2,000.00","2,000.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81410,Aortic dysfunction/dilation,Lab Services,Per Unit,$504.00 ,OP,504,504,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81411,Aortic dysfunction/dilation,Lab Services,Per Unit,"$1,350.19 ",OP,"1,350.19","1,350.19",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81412,Ashkenazi jewish assoc dis,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81413,Car ion chnnlpath inc 10 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81414,Car ion chnnlpath inc 2 gns,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81415,Exome sequence analysis,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81416,Exome sequence analysis,Lab Services,Per Unit,"$12,000.00 ",OP,"12,000.00","12,000.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81417,Exome re-evaluation,Lab Services,Per Unit,$320.00 ,OP,320,320,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81419,Epilepsy gen seq alys panel,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81420,Fetal chrmoml aneuploidy,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81422,Fetal chrmoml microdeltj,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81425,Genome sequence analysis,Lab Services,Per Unit,"$5,031.20 ",OP,"5,031.20","5,031.20",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81426,Genome sequence analysis,Lab Services,Per Unit,"$2,709.95 ",OP,"2,709.95","2,709.95",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81427,Genome re-evaluation,Lab Services,Per Unit,"$2,337.65 ",OP,"2,337.65","2,337.65",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81430,Hearing loss sequence analys,Lab Services,Per Unit,"$1,625.00 ",OP,"1,625.00","1,625.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81431,Hearing loss dup/del analys,Lab Services,Per Unit,$679.57 ,OP,679.57,679.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81432,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$679.05 ,OP,679.05,679.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81433,Hrdtry brst ca-rlatd dsordrs,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81434,Hereditary retinal disorders,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81435,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81436,Hereditary colon ca dsordrs,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81437,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81438,Heredtry nurondcrn tum dsrdr,Lab Services,Per Unit,$438.93 ,OP,438.93,438.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81439,Hrdtry cardmypy gene panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81440,Mitochondrial gene,Lab Services,Per Unit,"$3,324.00 ",OP,"3,324.00","3,324.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81442,Noonan spectrum disorders,Lab Services,Per Unit,"$2,143.60 ",OP,"2,143.60","2,143.60",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81443,Genetic tstg severe inh cond,Lab Services,Per Unit,"$2,448.56 ",OP,"2,448.56","2,448.56",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81445,Targeted genomic seq analys,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81448,Hrdtry perph neurphy panel,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81450,Targeted genomic seq analys,Lab Services,Per Unit,$759.53 ,OP,759.53,759.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81455,Targeted genomic seq analys,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81460,Whole mitochondrial genome,Lab Services,Per Unit,"$1,287.00 ",OP,"1,287.00","1,287.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81465,Whole mitochondrial genome,Lab Services,Per Unit,$936.00 ,OP,936,936,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81470,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81471,X-linked intellectual dblt,Lab Services,Per Unit,$914.00 ,OP,914,914,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81490,Autoimmune rheumatoid arthr,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81493,Cor artery disease mrna,Lab Services,Per Unit,"$1,050.00 ",OP,"1,050.00","1,050.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81500,Onco (ovar) two proteins,Lab Services,Per Unit,$260.50 ,OP,260.5,260.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81503,Onco (ovar) five proteins,Lab Services,Per Unit,$897.00 ,OP,897,897,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81504,Oncology tissue of origin,Lab Services,Per Unit,$520.00 ,OP,520,520,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81506,Endo assay seven anal,Lab Services,Per Unit,$68.92 ,OP,68.92,68.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81507,Fetal aneuploidy trisom risk,Lab Services,Per Unit,$795.00 ,OP,795,795,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81508,Ftl cgen abnor two proteins,Lab Services,Per Unit,$54.30 ,OP,54.3,54.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81509,Ftl cgen abnor 3 proteins,Lab Services,Per Unit,"$1,487.37 ",OP,"1,487.37","1,487.37",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81510,Ftl cgen abnor three anal,Lab Services,Per Unit,$55.54 ,OP,55.54,55.54,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81511,Ftl cgen abnor four anal,Lab Services,Per Unit,$153.50 ,OP,153.5,153.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81512,Ftl cgen abnor five anal,Lab Services,Per Unit,$69.52 ,OP,69.52,69.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81513,Nfct ds bv rna vag flu alg,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81514,Nfct ds bv&vaginitis dna alg,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81518,Onc brst mrna 11 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81519,Oncology breast mrna,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81520,Onc breast mrna 58 genes,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81521,Onc breast mrna 70 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81522,Onc breast mrna 12 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81525,Oncology colon mrna,Lab Services,Per Unit,"$3,116.00 ",OP,"3,116.00","3,116.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81528,Oncology colorectal scr,Lab Services,Per Unit,$508.87 ,OP,508.87,508.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81529,Onc cutan mlnma mrna 31 gene,Lab Services,Per Unit,"$7,193.00 ",OP,"7,193.00","7,193.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81535,Oncology gynecologic,Lab Services,Per Unit,$579.46 ,OP,579.46,579.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81536,Oncology gynecologic,Lab Services,Per Unit,$177.56 ,OP,177.56,177.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81538,Oncology lung,Lab Services,Per Unit,"$2,871.00 ",OP,"2,871.00","2,871.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81539,Oncology prostate prob score,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
United Healthcare VA PC3,CPT,81540,Oncology tum unknown origin,Lab Services,Per Unit,"$3,750.00 ",OP,"3,750.00","3,750.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81541,Onc prostate mrna 46 genes,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81542,Onc prostate mrna 22 cnt gen,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81546,Onc thyr mrna 10-196 gen alg,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81551,Onc prostate 3 genes,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81552,Onc uveal mlnma mrna 15 gene,Lab Services,Per Unit,"$7,776.00 ",OP,"7,776.00","7,776.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81554,Pulm ds ipf mrna 190 gen alg,Lab Services,Per Unit,"$5,500.00 ",OP,"5,500.00","5,500.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81595,Cardiology hrt trnspl mrna,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,81596,Nfct ds chrnc hcv 6 assays,Lab Services,Per Unit,$72.19 ,OP,72.19,72.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82009,Test for acetone/ketones,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82010,Acetone assay,Lab Services,Per Unit,$8.17 ,OP,8.17,8.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82013,Acetylcholinesterase assay,Lab Services,Per Unit,$12.29 ,OP,12.29,12.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82016,Acylcarnitines qual,Lab Services,Per Unit,$16.49 ,OP,16.49,16.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82017,Acylcarnitines quant,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82024,Assay of acth,Lab Services,Per Unit,$38.62 ,OP,38.62,38.62,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82030,Assay of adp & amp,Lab Services,Per Unit,$25.80 ,OP,25.8,25.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82040,Assay of serum albumin,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82042,Other source albumin quan ea,Lab Services,Per Unit,$7.78 ,OP,7.78,7.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82043,Ur albumin quantitative,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82044,Ur albumin semiquantitative,Lab Services,Per Unit,$6.23 ,OP,6.23,6.23,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82045,Albumin ischemia modified,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82075,Assay of breath ethanol,Lab Services,Per Unit,$30.00 ,OP,30,30,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82077,Assay spec xcp ur&breath ia,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82085,Assay of aldolase,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82088,Assay of aldosterone,Lab Services,Per Unit,$40.75 ,OP,40.75,40.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82103,Alpha-1-antitrypsin total,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82104,Alpha-1-antitrypsin pheno,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82105,Alpha-fetoprotein serum,Lab Services,Per Unit,$16.77 ,OP,16.77,16.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82106,Alpha-fetoprotein amniotic,Lab Services,Per Unit,$17.00 ,OP,17,17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82107,Alpha-fetoprotein l3,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82108,Assay of aluminum,Lab Services,Per Unit,$25.48 ,OP,25.48,25.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82120,Amines vaginal fluid qual,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82127,Amino acid single qual,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82128,Amino acids mult qual,Lab Services,Per Unit,$13.87 ,OP,13.87,13.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82131,Amino acids single quant,Lab Services,Per Unit,$22.98 ,OP,22.98,22.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82135,Assay aminolevulinic acid,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82136,Amino acids quant 2-5,Lab Services,Per Unit,$19.61 ,OP,19.61,19.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82139,Amino acids quan 6 or more,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82140,Assay of ammonia,Lab Services,Per Unit,$14.57 ,OP,14.57,14.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82143,Amniotic fluid scan,Lab Services,Per Unit,$9.35 ,OP,9.35,9.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82150,Assay of amylase,Lab Services,Per Unit,$6.48 ,OP,6.48,6.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82154,Androstanediol glucuronide,Lab Services,Per Unit,$28.83 ,OP,28.83,28.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82157,Assay of androstenedione,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82160,Assay of androsterone,Lab Services,Per Unit,$25.55 ,OP,25.55,25.55,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82163,Assay of angiotensin ii,Lab Services,Per Unit,$20.52 ,OP,20.52,20.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82164,Angiotensin i enzyme test,Lab Services,Per Unit,$14.60 ,OP,14.6,14.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82172,Assay of apolipoprotein,Lab Services,Per Unit,$21.09 ,OP,21.09,21.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82175,Assay of arsenic,Lab Services,Per Unit,$18.97 ,OP,18.97,18.97,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82180,Assay of ascorbic acid,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82190,Atomic absorption,Lab Services,Per Unit,$15.90 ,OP,15.9,15.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82232,Assay of beta-2 protein,Lab Services,Per Unit,$16.18 ,OP,16.18,16.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82239,Bile acids total,Lab Services,Per Unit,$17.12 ,OP,17.12,17.12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82240,Bile acids cholylglycine,Lab Services,Per Unit,$26.58 ,OP,26.58,26.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82247,Bilirubin total,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82248,Bilirubin direct,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82252,Fecal bilirubin test,Lab Services,Per Unit,$4.56 ,OP,4.56,4.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82261,Assay of biotinidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82270,Occult blood feces,Lab Services,Per Unit,$4.38 ,OP,4.38,4.38,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82271,Occult blood other sources,Lab Services,Per Unit,$5.32 ,OP,5.32,5.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82272,Occult bld feces 1-3 tests,Lab Services,Per Unit,$4.23 ,OP,4.23,4.23,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82274,Assay test for blood fecal,Lab Services,Per Unit,$15.92 ,OP,15.92,15.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82286,Assay of bradykinin,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82300,Assay of cadmium,Lab Services,Per Unit,$23.64 ,OP,23.64,23.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82306,Vitamin d 25 hydroxy,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82308,Assay of calcitonin,Lab Services,Per Unit,$26.79 ,OP,26.79,26.79,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82310,Assay of calcium,Lab Services,Per Unit,$5.16 ,OP,5.16,5.16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82330,Assay of calcium,Lab Services,Per Unit,$13.68 ,OP,13.68,13.68,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82331,Calcium infusion test,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82340,Assay of calcium in urine,Lab Services,Per Unit,$6.03 ,OP,6.03,6.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82355,Calculus analysis qual,Lab Services,Per Unit,$11.58 ,OP,11.58,11.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82360,Calculus assay quant,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82365,Calculus spectroscopy,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82370,X-ray assay calculus,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82373,Assay c-d transfer measure,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82374,Assay blood carbon dioxide,Lab Services,Per Unit,$4.88 ,OP,4.88,4.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82375,Assay carboxyhb quant,Lab Services,Per Unit,$12.32 ,OP,12.32,12.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82376,Assay carboxyhb qual,Lab Services,Per Unit,$14.07 ,OP,14.07,14.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82378,Carcinoembryonic antigen,Lab Services,Per Unit,$18.96 ,OP,18.96,18.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82379,Assay of carnitine,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82380,Assay of carotene,Lab Services,Per Unit,$9.22 ,OP,9.22,9.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82382,Assay urine catecholamines,Lab Services,Per Unit,$27.30 ,OP,27.3,27.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82383,Assay blood catecholamines,Lab Services,Per Unit,$29.08 ,OP,29.08,29.08,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82384,Assay three catecholamines,Lab Services,Per Unit,$25.25 ,OP,25.25,25.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82387,Assay of cathepsin-d,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82390,Assay of ceruloplasmin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82397,Chemiluminescent assay,Lab Services,Per Unit,$14.12 ,OP,14.12,14.12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82415,Assay of chloramphenicol,Lab Services,Per Unit,$12.67 ,OP,12.67,12.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82435,Assay of blood chloride,Lab Services,Per Unit,$4.60 ,OP,4.6,4.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82436,Assay of urine chloride,Lab Services,Per Unit,$5.75 ,OP,5.75,5.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82438,Assay other fluid chlorides,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82441,Test for chlorohydrocarbons,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82465,Assay bld/serum cholesterol,Lab Services,Per Unit,$4.35 ,OP,4.35,4.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82480,Assay serum cholinesterase,Lab Services,Per Unit,$7.87 ,OP,7.87,7.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82482,Assay rbc cholinesterase,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82485,Assay chondroitin sulfate,Lab Services,Per Unit,$20.65 ,OP,20.65,20.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82495,Assay of chromium,Lab Services,Per Unit,$20.28 ,OP,20.28,20.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82507,Assay of citrate,Lab Services,Per Unit,$27.80 ,OP,27.8,27.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82523,Collagen crosslinks,Lab Services,Per Unit,$18.68 ,OP,18.68,18.68,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82525,Assay of copper,Lab Services,Per Unit,$12.41 ,OP,12.41,12.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82528,Assay of corticosterone,Lab Services,Per Unit,$22.52 ,OP,22.52,22.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82530,Cortisol free,Lab Services,Per Unit,$16.71 ,OP,16.71,16.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82533,Total cortisol,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82540,Assay of creatine,Lab Services,Per Unit,$4.64 ,OP,4.64,4.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82542,Col chromotography qual/quan,Lab Services,Per Unit,$24.09 ,OP,24.09,24.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82550,Assay of ck (cpk),Lab Services,Per Unit,$6.51 ,OP,6.51,6.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82552,Assay of cpk in blood,Lab Services,Per Unit,$13.39 ,OP,13.39,13.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82553,Creatine mb fraction,Lab Services,Per Unit,$11.55 ,OP,11.55,11.55,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82554,Creatine isoforms,Lab Services,Per Unit,$11.87 ,OP,11.87,11.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82565,Assay of creatinine,Lab Services,Per Unit,$5.12 ,OP,5.12,5.12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82570,Assay of urine creatinine,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82575,Creatinine clearance test,Lab Services,Per Unit,$9.46 ,OP,9.46,9.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82585,Assay of cryofibrinogen,Lab Services,Per Unit,$14.14 ,OP,14.14,14.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82595,Assay of cryoglobulin,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82600,Assay of cyanide,Lab Services,Per Unit,$19.40 ,OP,19.4,19.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82607,Vitamin b-12,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82608,B-12 binding capacity,Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82610,Cystatin c,Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82615,Test for urine cystines,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82626,Dehydroepiandrosterone,Lab Services,Per Unit,$25.27 ,OP,25.27,25.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82627,Dehydroepiandrosterone,Lab Services,Per Unit,$22.23 ,OP,22.23,22.23,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82633,Desoxycorticosterone,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82634,Deoxycortisol,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82638,Assay of dibucaine number,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82642,Dihydrotestosterone,Lab Services,Per Unit,$29.28 ,OP,29.28,29.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82652,Vit d 1 25-dihydroxy,Lab Services,Per Unit,$38.50 ,OP,38.5,38.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82656,Pancreatic elastase fecal,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82657,Enzyme cell activity,Lab Services,Per Unit,$22.17 ,OP,22.17,22.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82658,Enzyme cell activity ra,Lab Services,Per Unit,$44.03 ,OP,44.03,44.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82664,Electrophoretic test,Lab Services,Per Unit,$61.50 ,OP,61.5,61.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82668,Assay of erythropoietin,Lab Services,Per Unit,$18.79 ,OP,18.79,18.79,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82670,Assay of total estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82671,Assay of estrogens,Lab Services,Per Unit,$32.30 ,OP,32.3,32.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82672,Assay of estrogen,Lab Services,Per Unit,$21.70 ,OP,21.7,21.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82677,Assay of estriol,Lab Services,Per Unit,$24.18 ,OP,24.18,24.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82679,Assay of estrone,Lab Services,Per Unit,$24.95 ,OP,24.95,24.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82681,Assay dir meas fr estradiol,Lab Services,Per Unit,$27.94 ,OP,27.94,27.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82693,Assay of ethylene glycol,Lab Services,Per Unit,$14.90 ,OP,14.9,14.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82696,Assay of etiocholanolone,Lab Services,Per Unit,$26.24 ,OP,26.24,26.24,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82705,Fats/lipids feces qual,Lab Services,Per Unit,$5.10 ,OP,5.1,5.1,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82710,Fats/lipids feces quant,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82715,Assay of fecal fat,Lab Services,Per Unit,$22.97 ,OP,22.97,22.97,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82725,Assay of blood fatty acids,Lab Services,Per Unit,$18.77 ,OP,18.77,18.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82726,Long chain fatty acids,Lab Services,Per Unit,$19.75 ,OP,19.75,19.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82728,Assay of ferritin,Lab Services,Per Unit,$13.63 ,OP,13.63,13.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82731,Assay of fetal fibronectin,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82735,Assay of fluoride,Lab Services,Per Unit,$18.54 ,OP,18.54,18.54,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82746,Assay of folic acid serum,Lab Services,Per Unit,$14.70 ,OP,14.7,14.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82747,Assay of folic acid rbc,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82757,Assay of semen fructose,Lab Services,Per Unit,$17.34 ,OP,17.34,17.34,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82759,Assay of rbc galactokinase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82760,Assay of galactose,Lab Services,Per Unit,$11.20 ,OP,11.2,11.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82775,Assay galactose transferase,Lab Services,Per Unit,$21.07 ,OP,21.07,21.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82776,Galactose transferase test,Lab Services,Per Unit,$11.74 ,OP,11.74,11.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82777,Galectin-3,Lab Services,Per Unit,$44.25 ,OP,44.25,44.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82784,Assay iga/igd/igg/igm each,Lab Services,Per Unit,$9.30 ,OP,9.3,9.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82785,Assay of ige,Lab Services,Per Unit,$16.46 ,OP,16.46,16.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82787,Igg 1 2 3 or 4 each,Lab Services,Per Unit,$8.02 ,OP,8.02,8.02,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82800,Blood ph,Lab Services,Per Unit,$11.00 ,OP,11,11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82803,Blood gases any combination,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82805,Blood gases w/o2 saturation,Lab Services,Per Unit,$78.77 ,OP,78.77,78.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82810,Blood gases o2 sat only,Lab Services,Per Unit,$9.77 ,OP,9.77,9.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82820,Hemoglobin-oxygen affinity,Lab Services,Per Unit,$13.34 ,OP,13.34,13.34,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82930,Gastric analy w/ph ea spec,Lab Services,Per Unit,$6.71 ,OP,6.71,6.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82938,Gastrin test,Lab Services,Per Unit,$17.69 ,OP,17.69,17.69,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82941,Assay of gastrin,Lab Services,Per Unit,$17.63 ,OP,17.63,17.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82943,Assay of glucagon,Lab Services,Per Unit,$14.29 ,OP,14.29,14.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82945,Glucose other fluid,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82946,Glucagon tolerance test,Lab Services,Per Unit,$17.77 ,OP,17.77,17.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82947,Assay glucose blood quant,Lab Services,Per Unit,$3.93 ,OP,3.93,3.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82948,Reagent strip/blood glucose,Lab Services,Per Unit,$5.04 ,OP,5.04,5.04,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82950,Glucose test,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82951,Glucose tolerance test (gtt),Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82952,Gtt-added samples,Lab Services,Per Unit,$3.92 ,OP,3.92,3.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82955,Assay of g6pd enzyme,Lab Services,Per Unit,$9.70 ,OP,9.7,9.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82960,Test for g6pd enzyme,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82962,Glucose blood test,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82963,Assay of glucosidase,Lab Services,Per Unit,$21.48 ,OP,21.48,21.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82965,Assay of gdh enzyme,Lab Services,Per Unit,$13.15 ,OP,13.15,13.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82977,Assay of ggt,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82978,Assay of glutathione,Lab Services,Per Unit,$15.45 ,OP,15.45,15.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82979,Assay rbc glutathione,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
United Healthcare VA PC3,CPT,82985,Assay of glycated protein,Lab Services,Per Unit,$16.76 ,OP,16.76,16.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83001,Assay of gonadotropin (fsh),Lab Services,Per Unit,$18.58 ,OP,18.58,18.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83002,Assay of gonadotropin (lh),Lab Services,Per Unit,$18.52 ,OP,18.52,18.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83003,Assay growth hormone (hgh),Lab Services,Per Unit,$16.67 ,OP,16.67,16.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83006,Growth stimulation gene 2,Lab Services,Per Unit,$75.60 ,OP,75.6,75.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83009,H pylori (c-13) blood,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83010,Assay of haptoglobin quant,Lab Services,Per Unit,$12.58 ,OP,12.58,12.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83012,Assay of haptoglobins,Lab Services,Per Unit,$26.89 ,OP,26.89,26.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83013,H pylori (c-13) breath,Lab Services,Per Unit,$67.36 ,OP,67.36,67.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83014,H pylori drug admin,Lab Services,Per Unit,$7.86 ,OP,7.86,7.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83015,Heavy metal qual any anal,Lab Services,Per Unit,$20.94 ,OP,20.94,20.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83018,Heavy metal quant each nes,Lab Services,Per Unit,$21.96 ,OP,21.96,21.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83020,Hemoglobin electrophoresis,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83021,Hemoglobin chromotography,Lab Services,Per Unit,$18.06 ,OP,18.06,18.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83026,Hemoglobin copper sulfate,Lab Services,Per Unit,$4.01 ,OP,4.01,4.01,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83030,Fetal hemoglobin chemical,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83033,Fetal hemoglobin assay qual,Lab Services,Per Unit,$8.00 ,OP,8,8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83036,Glycosylated hemoglobin test,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83037,Glycosylated hb home device,Lab Services,Per Unit,$9.71 ,OP,9.71,9.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83045,Blood methemoglobin test,Lab Services,Per Unit,$6.49 ,OP,6.49,6.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83050,Blood methemoglobin assay,Lab Services,Per Unit,$8.20 ,OP,8.2,8.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83051,Assay of plasma hemoglobin,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83060,Blood sulfhemoglobin assay,Lab Services,Per Unit,$8.80 ,OP,8.8,8.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83065,Assay of hemoglobin heat,Lab Services,Per Unit,$9.00 ,OP,9,9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83068,Hemoglobin stability screen,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83069,Assay of urine hemoglobin,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83070,Assay of hemosiderin qual,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83080,Assay of b hexosaminidase,Lab Services,Per Unit,$16.87 ,OP,16.87,16.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83088,Assay of histamine,Lab Services,Per Unit,$29.53 ,OP,29.53,29.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83090,Assay of homocystine,Lab Services,Per Unit,$17.92 ,OP,17.92,17.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83150,Assay of homovanillic acid,Lab Services,Per Unit,$22.41 ,OP,22.41,22.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83491,Assay of corticosteroids 17,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83497,Assay of 5-hiaa,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83498,Assay of progesterone 17-d,Lab Services,Per Unit,$27.17 ,OP,27.17,27.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83500,Assay free hydroxyproline,Lab Services,Per Unit,$22.65 ,OP,22.65,22.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83505,Assay total hydroxyproline,Lab Services,Per Unit,$24.30 ,OP,24.3,24.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83516,Immunoassay nonantibody,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83518,Immunoassay dipstick,Lab Services,Per Unit,$9.64 ,OP,9.64,9.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83519,Ria nonantibody,Lab Services,Per Unit,$18.40 ,OP,18.4,18.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83520,Immunoassay quant nos nonab,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83525,Assay of insulin,Lab Services,Per Unit,$11.43 ,OP,11.43,11.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83527,Assay of insulin,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83528,Assay of intrinsic factor,Lab Services,Per Unit,$19.82 ,OP,19.82,19.82,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83540,Assay of iron,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83550,Iron binding test,Lab Services,Per Unit,$8.74 ,OP,8.74,8.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83570,Assay of idh enzyme,Lab Services,Per Unit,$8.85 ,OP,8.85,8.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83582,Assay of ketogenic steroids,Lab Services,Per Unit,$15.47 ,OP,15.47,15.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83586,Assay 17- ketosteroids,Lab Services,Per Unit,$12.80 ,OP,12.8,12.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83593,Fractionation ketosteroids,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83605,Assay of lactic acid,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83615,Lactate (ld) (ldh) enzyme,Lab Services,Per Unit,$6.04 ,OP,6.04,6.04,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83625,Assay of ldh enzymes,Lab Services,Per Unit,$12.79 ,OP,12.79,12.79,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83630,Lactoferrin fecal (qual),Lab Services,Per Unit,$19.70 ,OP,19.7,19.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83631,Lactoferrin fecal (quant),Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83632,Placental lactogen,Lab Services,Per Unit,$20.22 ,OP,20.22,20.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83633,Test urine for lactose,Lab Services,Per Unit,$11.25 ,OP,11.25,11.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83655,Assay of lead,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83661,L/s ratio fetal lung,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83662,Foam stability fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83663,Fluoro polarize fetal lung,Lab Services,Per Unit,$18.91 ,OP,18.91,18.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83664,Lamellar bdy fetal lung,Lab Services,Per Unit,$19.32 ,OP,19.32,19.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83670,Assay of lap enzyme,Lab Services,Per Unit,$9.81 ,OP,9.81,9.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83690,Assay of lipase,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83695,Assay of lipoprotein(a),Lab Services,Per Unit,$14.32 ,OP,14.32,14.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83698,Assay lipoprotein pla2,Lab Services,Per Unit,$46.31 ,OP,46.31,46.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83700,Lipopro bld electrophoretic,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83701,Lipoprotein bld hr fraction,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83704,Lipoprotein bld quan part,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83718,Assay of lipoprotein,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83719,Assay of blood lipoprotein,Lab Services,Per Unit,$12.75 ,OP,12.75,12.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83721,Assay of blood lipoprotein,Lab Services,Per Unit,$10.50 ,OP,10.5,10.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83722,Lipoprtn dir meas sd ldl chl,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83727,Assay of lrh hormone,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83735,Assay of magnesium,Lab Services,Per Unit,$6.70 ,OP,6.7,6.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83775,Assay malate dehydrogenase,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83785,Assay of manganese,Lab Services,Per Unit,$26.65 ,OP,26.65,26.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83789,Mass spectrometry qual/quan,Lab Services,Per Unit,$24.11 ,OP,24.11,24.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83825,Assay of mercury,Lab Services,Per Unit,$16.26 ,OP,16.26,16.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83835,Assay of metanephrines,Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83857,Assay of methemalbumin,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83861,Microfluid analy tears,Lab Services,Per Unit,$22.48 ,OP,22.48,22.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83864,Mucopolysaccharides,Lab Services,Per Unit,$28.50 ,OP,28.5,28.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83872,Assay synovial fluid mucin,Lab Services,Per Unit,$5.86 ,OP,5.86,5.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83873,Assay of csf protein,Lab Services,Per Unit,$17.20 ,OP,17.2,17.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83874,Assay of myoglobin,Lab Services,Per Unit,$12.92 ,OP,12.92,12.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83876,Assay myeloperoxidase,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83880,Assay of natriuretic peptide,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83883,Assay nephelometry not spec,Lab Services,Per Unit,$13.60 ,OP,13.6,13.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83885,Assay of nickel,Lab Services,Per Unit,$24.51 ,OP,24.51,24.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83915,Assay of nucleotidase,Lab Services,Per Unit,$11.15 ,OP,11.15,11.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83916,Oligoclonal bands,Lab Services,Per Unit,$27.39 ,OP,27.39,27.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83918,Organic acids total quant,Lab Services,Per Unit,$23.60 ,OP,23.6,23.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83919,Organic acids qual each,Lab Services,Per Unit,$16.45 ,OP,16.45,16.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83921,Organic acid single quant,Lab Services,Per Unit,$21.21 ,OP,21.21,21.21,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83930,Assay of blood osmolality,Lab Services,Per Unit,$6.61 ,OP,6.61,6.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83935,Assay of urine osmolality,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83937,Assay of osteocalcin,Lab Services,Per Unit,$29.85 ,OP,29.85,29.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83945,Assay of oxalate,Lab Services,Per Unit,$14.45 ,OP,14.45,14.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83950,Oncoprotein her-2/neu,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83951,Oncoprotein dcp,Lab Services,Per Unit,$64.41 ,OP,64.41,64.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83970,Assay of parathormone,Lab Services,Per Unit,$41.28 ,OP,41.28,41.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83986,Assay ph body fluid nos,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83987,Exhaled breath condensate,Lab Services,Per Unit,$3.58 ,OP,3.58,3.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,83993,Assay for calprotectin fecal,Lab Services,Per Unit,$19.63 ,OP,19.63,19.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84030,Assay of blood pku,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84035,Assay of phenylketones,Lab Services,Per Unit,$3.98 ,OP,3.98,3.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84060,Assay acid phosphatase,Lab Services,Per Unit,$7.64 ,OP,7.64,7.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84066,Assay prostate phosphatase,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84075,Assay alkaline phosphatase,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84078,Assay alkaline phosphatase,Lab Services,Per Unit,$8.26 ,OP,8.26,8.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84080,Assay alkaline phosphatases,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84081,Assay phosphatidylglycerol,Lab Services,Per Unit,$16.52 ,OP,16.52,16.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84085,Assay of rbc pg6d enzyme,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84087,Assay phosphohexose enzymes,Lab Services,Per Unit,$10.73 ,OP,10.73,10.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84100,Assay of phosphorus,Lab Services,Per Unit,$4.74 ,OP,4.74,4.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84105,Assay of urine phosphorus,Lab Services,Per Unit,$5.78 ,OP,5.78,5.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84106,Test for porphobilinogen,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84110,Assay of porphobilinogen,Lab Services,Per Unit,$8.44 ,OP,8.44,8.44,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84112,Eval amniotic fluid protein,Lab Services,Per Unit,$98.11 ,OP,98.11,98.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84119,Test urine for porphyrins,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84120,Assay of urine porphyrins,Lab Services,Per Unit,$14.71 ,OP,14.71,14.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84126,Assay of feces porphyrins,Lab Services,Per Unit,$39.11 ,OP,39.11,39.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84132,Assay of serum potassium,Lab Services,Per Unit,$4.76 ,OP,4.76,4.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84133,Assay of urine potassium,Lab Services,Per Unit,$4.73 ,OP,4.73,4.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84134,Assay of prealbumin,Lab Services,Per Unit,$14.59 ,OP,14.59,14.59,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84135,Assay of pregnanediol,Lab Services,Per Unit,$21.27 ,OP,21.27,21.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84138,Assay of pregnanetriol,Lab Services,Per Unit,$21.05 ,OP,21.05,21.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84140,Assay of pregnenolone,Lab Services,Per Unit,$20.67 ,OP,20.67,20.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84143,Assay of 17-hydroxypregneno,Lab Services,Per Unit,$22.81 ,OP,22.81,22.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84144,Assay of progesterone,Lab Services,Per Unit,$20.86 ,OP,20.86,20.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84145,Procalcitonin (pct),Lab Services,Per Unit,$27.22 ,OP,27.22,27.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84146,Assay of prolactin,Lab Services,Per Unit,$19.38 ,OP,19.38,19.38,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84150,Assay of prostaglandin,Lab Services,Per Unit,$41.77 ,OP,41.77,41.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84152,Assay of psa complexed,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84153,Assay of psa total,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84154,Assay of psa free,Lab Services,Per Unit,$18.39 ,OP,18.39,18.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84155,Assay of protein serum,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84156,Assay of protein urine,Lab Services,Per Unit,$3.67 ,OP,3.67,3.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84157,Assay of protein other,Lab Services,Per Unit,$4.00 ,OP,4,4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84160,Assay of protein any source,Lab Services,Per Unit,$5.61 ,OP,5.61,5.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84163,Pappa serum,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84165,Protein e-phoresis serum,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84166,Protein e-phoresis/urine/csf,Lab Services,Per Unit,$17.83 ,OP,17.83,17.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84181,Western blot test,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84182,Protein western blot test,Lab Services,Per Unit,$29.21 ,OP,29.21,29.21,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84202,Assay rbc protoporphyrin,Lab Services,Per Unit,$14.35 ,OP,14.35,14.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84203,Test rbc protoporphyrin,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84206,Assay of proinsulin,Lab Services,Per Unit,$26.69 ,OP,26.69,26.69,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84207,Assay of vitamin b-6,Lab Services,Per Unit,$28.10 ,OP,28.1,28.1,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84210,Assay of pyruvate,Lab Services,Per Unit,$14.48 ,OP,14.48,14.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84220,Assay of pyruvate kinase,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84228,Assay of quinine,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84233,Assay of estrogen,Lab Services,Per Unit,$87.88 ,OP,87.88,87.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84234,Assay of progesterone,Lab Services,Per Unit,$64.88 ,OP,64.88,64.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84235,Assay of endocrine hormone,Lab Services,Per Unit,$71.23 ,OP,71.23,71.23,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84238,Assay nonendocrine receptor,Lab Services,Per Unit,$36.57 ,OP,36.57,36.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84244,Assay of renin,Lab Services,Per Unit,$21.99 ,OP,21.99,21.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84252,Assay of vitamin b-2,Lab Services,Per Unit,$20.24 ,OP,20.24,20.24,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84255,Assay of selenium,Lab Services,Per Unit,$25.53 ,OP,25.53,25.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84260,Assay of serotonin,Lab Services,Per Unit,$30.98 ,OP,30.98,30.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84270,Assay of sex hormone globul,Lab Services,Per Unit,$21.73 ,OP,21.73,21.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84275,Assay of sialic acid,Lab Services,Per Unit,$13.44 ,OP,13.44,13.44,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84285,Assay of silica,Lab Services,Per Unit,$25.21 ,OP,25.21,25.21,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84295,Assay of serum sodium,Lab Services,Per Unit,$4.81 ,OP,4.81,4.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84300,Assay of urine sodium,Lab Services,Per Unit,$5.06 ,OP,5.06,5.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84302,Assay of sweat sodium,Lab Services,Per Unit,$4.86 ,OP,4.86,4.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84305,Assay of somatomedin,Lab Services,Per Unit,$21.26 ,OP,21.26,21.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84307,Assay of somatostatin,Lab Services,Per Unit,$18.28 ,OP,18.28,18.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84311,Spectrophotometry,Lab Services,Per Unit,$8.10 ,OP,8.1,8.1,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84315,Body fluid specific gravity,Lab Services,Per Unit,$3.28 ,OP,3.28,3.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84375,Chromatogram assay sugars,Lab Services,Per Unit,$39.00 ,OP,39,39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84376,Sugars single qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84377,Sugars multiple qual,Lab Services,Per Unit,$5.50 ,OP,5.5,5.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84378,Sugars single quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84379,Sugars multiple quant,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84392,Assay of urine sulfate,Lab Services,Per Unit,$5.49 ,OP,5.49,5.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84402,Assay of free testosterone,Lab Services,Per Unit,$25.47 ,OP,25.47,25.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84403,Assay of total testosterone,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84410,Testosterone bioavailable,Lab Services,Per Unit,$51.28 ,OP,51.28,51.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84425,Assay of vitamin b-1,Lab Services,Per Unit,$21.23 ,OP,21.23,21.23,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84430,Assay of thiocyanate,Lab Services,Per Unit,$11.63 ,OP,11.63,11.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84431,Thromboxane urine,Lab Services,Per Unit,$35.11 ,OP,35.11,35.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84432,Assay of thyroglobulin,Lab Services,Per Unit,$16.06 ,OP,16.06,16.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84436,Assay of total thyroxine,Lab Services,Per Unit,$6.87 ,OP,6.87,6.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84437,Assay of neonatal thyroxine,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84439,Assay of free thyroxine,Lab Services,Per Unit,$9.02 ,OP,9.02,9.02,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84442,Assay of thyroid activity,Lab Services,Per Unit,$14.78 ,OP,14.78,14.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84443,Assay thyroid stim hormone,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84445,Assay of tsi globulin,Lab Services,Per Unit,$50.86 ,OP,50.86,50.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84446,Assay of vitamin e,Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84449,Assay of transcortin,Lab Services,Per Unit,$18.00 ,OP,18,18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84450,Transferase (ast) (sgot),Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84460,Alanine amino (alt) (sgpt),Lab Services,Per Unit,$5.30 ,OP,5.3,5.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84466,Assay of transferrin,Lab Services,Per Unit,$12.76 ,OP,12.76,12.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84478,Assay of triglycerides,Lab Services,Per Unit,$5.74 ,OP,5.74,5.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84479,Assay of thyroid (t3 or t4),Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84480,Assay triiodothyronine (t3),Lab Services,Per Unit,$14.18 ,OP,14.18,14.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84481,Free assay (ft-3),Lab Services,Per Unit,$16.94 ,OP,16.94,16.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84482,T3 reverse,Lab Services,Per Unit,$15.76 ,OP,15.76,15.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84484,Assay of troponin quant,Lab Services,Per Unit,$12.47 ,OP,12.47,12.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84485,Assay duodenal fluid trypsin,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84488,Test feces for trypsin,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84490,Assay of feces for trypsin,Lab Services,Per Unit,$9.93 ,OP,9.93,9.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84510,Assay of tyrosine,Lab Services,Per Unit,$10.63 ,OP,10.63,10.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84512,Assay of troponin qual,Lab Services,Per Unit,$10.09 ,OP,10.09,10.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84520,Assay of urea nitrogen,Lab Services,Per Unit,$3.95 ,OP,3.95,3.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84525,Urea nitrogen semi-quant,Lab Services,Per Unit,$5.13 ,OP,5.13,5.13,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84540,Assay of urine/urea-n,Lab Services,Per Unit,$5.56 ,OP,5.56,5.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84545,Urea-n clearance test,Lab Services,Per Unit,$7.20 ,OP,7.2,7.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84550,Assay of blood/uric acid,Lab Services,Per Unit,$4.52 ,OP,4.52,4.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84560,Assay of urine/uric acid,Lab Services,Per Unit,$5.08 ,OP,5.08,5.08,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84577,Assay of feces/urobilinogen,Lab Services,Per Unit,$16.80 ,OP,16.8,16.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84578,Test urine urobilinogen,Lab Services,Per Unit,$4.47 ,OP,4.47,4.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84580,Assay of urine urobilinogen,Lab Services,Per Unit,$9.55 ,OP,9.55,9.55,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84583,Assay of urine urobilinogen,Lab Services,Per Unit,$6.05 ,OP,6.05,6.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84585,Assay of urine vma,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84586,Assay of vip,Lab Services,Per Unit,$35.33 ,OP,35.33,35.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84588,Assay of vasopressin,Lab Services,Per Unit,$33.94 ,OP,33.94,33.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84590,Assay of vitamin a,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84591,Assay of nos vitamin,Lab Services,Per Unit,$17.06 ,OP,17.06,17.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84597,Assay of vitamin k,Lab Services,Per Unit,$13.72 ,OP,13.72,13.72,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84600,Assay of volatiles,Lab Services,Per Unit,$17.11 ,OP,17.11,17.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84620,Xylose tolerance test,Lab Services,Per Unit,$12.91 ,OP,12.91,12.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84630,Assay of zinc,Lab Services,Per Unit,$11.39 ,OP,11.39,11.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84681,Assay of c-peptide,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84702,Chorionic gonadotropin test,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84703,Chorionic gonadotropin assay,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84704,Hcg free betachain test,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,84830,Ovulation tests,Lab Services,Per Unit,$12.70 ,OP,12.7,12.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85002,Bleeding time test,Lab Services,Per Unit,$4.82 ,OP,4.82,4.82,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85004,Automated diff wbc count,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85007,Bl smear w/diff wbc count,Lab Services,Per Unit,$3.80 ,OP,3.8,3.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85008,Bl smear w/o diff wbc count,Lab Services,Per Unit,$3.43 ,OP,3.43,3.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85009,Manual diff wbc count b-coat,Lab Services,Per Unit,$5.07 ,OP,5.07,5.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85013,Spun microhematocrit,Lab Services,Per Unit,$7.00 ,OP,7,7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85014,Hematocrit,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85018,Hemoglobin,Lab Services,Per Unit,$2.37 ,OP,2.37,2.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85025,Complete cbc w/auto diff wbc,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85027,Complete cbc automated,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85032,Manual cell count each,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85041,Automated rbc count,Lab Services,Per Unit,$3.02 ,OP,3.02,3.02,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85044,Manual reticulocyte count,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85045,Automated reticulocyte count,Lab Services,Per Unit,$3.99 ,OP,3.99,3.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85046,Reticyte/hgb concentrate,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85048,Automated leukocyte count,Lab Services,Per Unit,$2.54 ,OP,2.54,2.54,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85049,Automated platelet count,Lab Services,Per Unit,$4.48 ,OP,4.48,4.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85055,Reticulated platelet assay,Lab Services,Per Unit,$35.74 ,OP,35.74,35.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85130,Chromogenic substrate assay,Lab Services,Per Unit,$11.89 ,OP,11.89,11.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85170,Blood clot retraction,Lab Services,Per Unit,$16.30 ,OP,16.3,16.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85175,Blood clot lysis time,Lab Services,Per Unit,$20.37 ,OP,20.37,20.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85210,Clot factor ii prothrom spec,Lab Services,Per Unit,$12.98 ,OP,12.98,12.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85220,Blooc clot factor v test,Lab Services,Per Unit,$17.65 ,OP,17.65,17.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85230,Clot factor vii proconvertin,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85240,Clot factor viii ahg 1 stage,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85244,Clot factor viii reltd antgn,Lab Services,Per Unit,$20.42 ,OP,20.42,20.42,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85245,Clot factor viii vw ristoctn,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85246,Clot factor viii vw antigen,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85247,Clot factor viii multimetric,Lab Services,Per Unit,$22.94 ,OP,22.94,22.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85250,Clot factor ix ptc/chrstmas,Lab Services,Per Unit,$19.04 ,OP,19.04,19.04,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85260,Clot factor x stuart-power,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85270,Clot factor xi pta,Lab Services,Per Unit,$17.90 ,OP,17.9,17.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85280,Clot factor xii hageman,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85290,Clot factor xiii fibrin stab,Lab Services,Per Unit,$16.34 ,OP,16.34,16.34,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85291,Clot factor xiii fibrin scrn,Lab Services,Per Unit,$9.11 ,OP,9.11,9.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85292,Clot factor fletcher fact,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85293,Clot factor wght kininogen,Lab Services,Per Unit,$18.93 ,OP,18.93,18.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85300,Antithrombin iii activity,Lab Services,Per Unit,$11.85 ,OP,11.85,11.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85301,Antithrombin iii antigen,Lab Services,Per Unit,$10.81 ,OP,10.81,10.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85302,Clot inhibit prot c antigen,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85303,Clot inhibit prot c activity,Lab Services,Per Unit,$13.84 ,OP,13.84,13.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85305,Clot inhibit prot s total,Lab Services,Per Unit,$11.61 ,OP,11.61,11.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85306,Clot inhibit prot s free,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85307,Assay activated protein c,Lab Services,Per Unit,$15.32 ,OP,15.32,15.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85335,Factor inhibitor test,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85337,Thrombomodulin,Lab Services,Per Unit,$17.27 ,OP,17.27,17.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85345,Coagulation time lee & white,Lab Services,Per Unit,$4.69 ,OP,4.69,4.69,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85347,Coagulation time activated,Lab Services,Per Unit,$4.28 ,OP,4.28,4.28,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85348,Coagulation time otr method,Lab Services,Per Unit,$4.49 ,OP,4.49,4.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85360,Euglobulin lysis,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85362,Fibrin degradation products,Lab Services,Per Unit,$6.89 ,OP,6.89,6.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85366,Fibrinogen test,Lab Services,Per Unit,$80.46 ,OP,80.46,80.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85370,Fibrinogen test,Lab Services,Per Unit,$12.43 ,OP,12.43,12.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85378,Fibrin degrade semiquant,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85379,Fibrin degradation quant,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85380,Fibrin degradj d-dimer,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85384,Fibrinogen activity,Lab Services,Per Unit,$9.72 ,OP,9.72,9.72,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85385,Fibrinogen antigen,Lab Services,Per Unit,$14.46 ,OP,14.46,14.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85390,Fibrinolysins screen i&r,Lab Services,Per Unit,$15.48 ,OP,15.48,15.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85397,Clotting funct activity,Lab Services,Per Unit,$30.86 ,OP,30.86,30.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85400,Fibrinolytic plasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85410,Fibrinolytic antiplasmin,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85415,Fibrinolytic plasminogen,Lab Services,Per Unit,$17.19 ,OP,17.19,17.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85420,Fibrinolytic plasminogen,Lab Services,Per Unit,$6.53 ,OP,6.53,6.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85421,Fibrinolytic plasminogen,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85441,Heinz bodies direct,Lab Services,Per Unit,$4.20 ,OP,4.2,4.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85445,Heinz bodies induced,Lab Services,Per Unit,$6.82 ,OP,6.82,6.82,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85460,Hemoglobin fetal,Lab Services,Per Unit,$7.73 ,OP,7.73,7.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85461,Hemoglobin fetal,Lab Services,Per Unit,$9.36 ,OP,9.36,9.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85475,Hemolysin acid,Lab Services,Per Unit,$8.87 ,OP,8.87,8.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85520,Heparin assay,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85525,Heparin neutralization,Lab Services,Per Unit,$11.84 ,OP,11.84,11.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85530,Heparin-protamine tolerance,Lab Services,Per Unit,$13.09 ,OP,13.09,13.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85536,Iron stain peripheral blood,Lab Services,Per Unit,$6.88 ,OP,6.88,6.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85540,Wbc alkaline phosphatase,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85547,Rbc mechanical fragility,Lab Services,Per Unit,$8.60 ,OP,8.6,8.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85549,Muramidase,Lab Services,Per Unit,$18.75 ,OP,18.75,18.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85555,Rbc osmotic fragility,Lab Services,Per Unit,$7.47 ,OP,7.47,7.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85557,Rbc osmotic fragility,Lab Services,Per Unit,$13.36 ,OP,13.36,13.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85576,Blood platelet aggregation,Lab Services,Per Unit,$24.91 ,OP,24.91,24.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85597,Phospholipid pltlt neutraliz,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85598,Hexagnal phosph pltlt neutrl,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85610,Prothrombin time,Lab Services,Per Unit,$4.29 ,OP,4.29,4.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85611,Prothrombin test,Lab Services,Per Unit,$3.94 ,OP,3.94,3.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85612,Viper venom prothrombin time,Lab Services,Per Unit,$17.49 ,OP,17.49,17.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85613,Russell viper venom diluted,Lab Services,Per Unit,$9.58 ,OP,9.58,9.58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85635,Reptilase test,Lab Services,Per Unit,$9.85 ,OP,9.85,9.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85651,Rbc sed rate nonautomated,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85652,Rbc sed rate automated,Lab Services,Per Unit,$2.70 ,OP,2.7,2.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85660,Rbc sickle cell test,Lab Services,Per Unit,$5.51 ,OP,5.51,5.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85670,Thrombin time plasma,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85675,Thrombin time titer,Lab Services,Per Unit,$6.85 ,OP,6.85,6.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85705,Thromboplastin inhibition,Lab Services,Per Unit,$9.63 ,OP,9.63,9.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85730,Thromboplastin time partial,Lab Services,Per Unit,$6.01 ,OP,6.01,6.01,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85732,Thromboplastin time partial,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,85810,Blood viscosity examination,Lab Services,Per Unit,$11.67 ,OP,11.67,11.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86000,Agglutinins febrile antigen,Lab Services,Per Unit,$6.98 ,OP,6.98,6.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86001,Allergen specific igg,Lab Services,Per Unit,$7.82 ,OP,7.82,7.82,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86003,Allg spec ige crude xtrc ea,Lab Services,Per Unit,$5.22 ,OP,5.22,5.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86005,Allg spec ige multiallg scr,Lab Services,Per Unit,$7.97 ,OP,7.97,7.97,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86008,Allg spec ige recomb ea,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86021,Wbc antibody identification,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86022,Platelet antibodies,Lab Services,Per Unit,$18.37 ,OP,18.37,18.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86023,Immunoglobulin assay,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86038,Antinuclear antibodies,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86039,Antinuclear antibodies (ana),Lab Services,Per Unit,$11.16 ,OP,11.16,11.16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86060,Antistreptolysin o titer,Lab Services,Per Unit,$7.30 ,OP,7.3,7.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86063,Antistreptolysin o screen,Lab Services,Per Unit,$5.77 ,OP,5.77,5.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86140,C-reactive protein,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86141,C-reactive protein hs,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86146,Beta-2 glycoprotein antibody,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86147,Cardiolipin antibody ea ig,Lab Services,Per Unit,$25.45 ,OP,25.45,25.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86148,Anti-phospholipid antibody,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86152,Cell enumeration & id,Lab Services,Per Unit,$250.78 ,OP,250.78,250.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86155,Chemotaxis assay,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86156,Cold agglutinin screen,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86157,Cold agglutinin titer,Lab Services,Per Unit,$8.06 ,OP,8.06,8.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86160,Complement antigen,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86161,Complement/function activity,Lab Services,Per Unit,$12.00 ,OP,12,12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86162,Complement total (ch50),Lab Services,Per Unit,$20.32 ,OP,20.32,20.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86171,Complement fixation each,Lab Services,Per Unit,$10.01 ,OP,10.01,10.01,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86200,Ccp antibody,Lab Services,Per Unit,$12.95 ,OP,12.95,12.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86215,Deoxyribonuclease antibody,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86225,Dna antibody native,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86226,Dna antibody single strand,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86235,Nuclear antigen antibody,Lab Services,Per Unit,$17.93 ,OP,17.93,17.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86255,Fluorescent antibody screen,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86256,Fluorescent antibody titer,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86277,Growth hormone antibody,Lab Services,Per Unit,$15.74 ,OP,15.74,15.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86280,Hemagglutination inhibition,Lab Services,Per Unit,$8.19 ,OP,8.19,8.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86294,Immunoassay tumor qual,Lab Services,Per Unit,$25.57 ,OP,25.57,25.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86300,Immunoassay tumor ca 15-3,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86301,Immunoassay tumor ca 19-9,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86304,Immunoassay tumor ca 125,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86305,Human epididymis protein 4,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86308,Heterophile antibody screen,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86309,Heterophile antibody titer,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86310,Heterophile antibody absrbj,Lab Services,Per Unit,$7.37 ,OP,7.37,7.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86316,Immunoassay tumor other,Lab Services,Per Unit,$20.81 ,OP,20.81,20.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86317,Immunoassay infectious agent,Lab Services,Per Unit,$14.99 ,OP,14.99,14.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86318,Ia infectious agent antibody,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86320,Serum immunoelectrophoresis,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86325,Other immunoelectrophoresis,Lab Services,Per Unit,$23.13 ,OP,23.13,23.13,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86327,Immunoelectrophoresis assay,Lab Services,Per Unit,$29.92 ,OP,29.92,29.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86329,Immunodiffusion nes,Lab Services,Per Unit,$14.05 ,OP,14.05,14.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86331,Immunodiffusion ouchterlony,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86332,Immune complex assay,Lab Services,Per Unit,$24.37 ,OP,24.37,24.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86334,Immunofix e-phoresis serum,Lab Services,Per Unit,$22.34 ,OP,22.34,22.34,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86335,Immunfix e-phorsis/urine/csf,Lab Services,Per Unit,$29.35 ,OP,29.35,29.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86336,Inhibin a,Lab Services,Per Unit,$15.59 ,OP,15.59,15.59,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86337,Insulin antibodies,Lab Services,Per Unit,$21.41 ,OP,21.41,21.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86340,Intrinsic factor antibody,Lab Services,Per Unit,$15.08 ,OP,15.08,15.08,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86341,Islet cell antibody,Lab Services,Per Unit,$23.57 ,OP,23.57,23.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86343,Leukocyte histamine release,Lab Services,Per Unit,$12.46 ,OP,12.46,12.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86344,Leukocyte phagocytosis,Lab Services,Per Unit,$10.39 ,OP,10.39,10.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86352,Cell function assay w/stim,Lab Services,Per Unit,$135.86 ,OP,135.86,135.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86353,Lymphocyte transformation,Lab Services,Per Unit,$49.03 ,OP,49.03,49.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86355,B cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86356,Mononuclear cell antigen,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86357,Nk cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86359,T cells total count,Lab Services,Per Unit,$37.73 ,OP,37.73,37.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86360,T cell absolute count/ratio,Lab Services,Per Unit,$46.98 ,OP,46.98,46.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86361,T cell absolute count,Lab Services,Per Unit,$26.78 ,OP,26.78,26.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86367,Stem cells total count,Lab Services,Per Unit,$77.78 ,OP,77.78,77.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86376,Microsomal antibody each,Lab Services,Per Unit,$14.55 ,OP,14.55,14.55,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86382,Neutralization test viral,Lab Services,Per Unit,$16.91 ,OP,16.91,16.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86384,Nitroblue tetrazolium dye,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86386,Nuclear matrix protein 22,Lab Services,Per Unit,$21.78 ,OP,21.78,21.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86403,Particle agglut antbdy scrn,Lab Services,Per Unit,$11.54 ,OP,11.54,11.54,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86406,Particle agglut antbdy titr,Lab Services,Per Unit,$10.64 ,OP,10.64,10.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86430,Rheumatoid factor test qual,Lab Services,Per Unit,$6.14 ,OP,6.14,6.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86431,Rheumatoid factor quant,Lab Services,Per Unit,$5.67 ,OP,5.67,5.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86480,Tb test cell immun measure,Lab Services,Per Unit,$61.98 ,OP,61.98,61.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86481,Tb ag response t-cell susp,Lab Services,Per Unit,$100.00 ,OP,100,100,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86590,Streptokinase antibody,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86592,Syphilis test non-trep qual,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86593,Syphilis test non-trep quant,Lab Services,Per Unit,$4.40 ,OP,4.4,4.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86602,Antinomyces antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86603,Adenovirus antibody,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86606,Aspergillus antibody,Lab Services,Per Unit,$15.05 ,OP,15.05,15.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86609,Bacterium antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86611,Bartonella antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86612,Blastomyces antibody,Lab Services,Per Unit,$12.90 ,OP,12.9,12.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86615,Bordetella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86617,Lyme disease antibody,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86618,Lyme disease antibody,Lab Services,Per Unit,$17.03 ,OP,17.03,17.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86619,Borrelia antibody,Lab Services,Per Unit,$13.38 ,OP,13.38,13.38,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86622,Brucella antibody,Lab Services,Per Unit,$8.93 ,OP,8.93,8.93,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86625,Campylobacter antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86628,Candida antibody,Lab Services,Per Unit,$12.01 ,OP,12.01,12.01,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86631,Chlamydia antibody,Lab Services,Per Unit,$11.82 ,OP,11.82,11.82,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86632,Chlamydia igm antibody,Lab Services,Per Unit,$12.68 ,OP,12.68,12.68,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86635,Coccidioides antibody,Lab Services,Per Unit,$11.47 ,OP,11.47,11.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86638,Q fever antibody,Lab Services,Per Unit,$12.12 ,OP,12.12,12.12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86641,Cryptococcus antibody,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86644,Cmv antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86645,Cmv antibody igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86648,Diphtheria antibody,Lab Services,Per Unit,$15.21 ,OP,15.21,15.21,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86651,Encephalitis californ antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86652,Encephaltis east eqne anbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86653,Encephaltis st louis antbody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86654,Encephaltis west eqne antbdy,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86658,Enterovirus antibody,Lab Services,Per Unit,$13.03 ,OP,13.03,13.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86663,Epstein-barr antibody,Lab Services,Per Unit,$13.12 ,OP,13.12,13.12,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86664,Epstein-barr nuclear antigen,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86665,Epstein-barr capsid vca,Lab Services,Per Unit,$18.14 ,OP,18.14,18.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86666,Ehrlichia antibody,Lab Services,Per Unit,$10.18 ,OP,10.18,10.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86668,Francisella tularensis,Lab Services,Per Unit,$14.16 ,OP,14.16,14.16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86671,Fungus nes antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86674,Giardia lamblia antibody,Lab Services,Per Unit,$14.72 ,OP,14.72,14.72,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86677,Helicobacter pylori antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86682,Helminth antibody,Lab Services,Per Unit,$13.01 ,OP,13.01,13.01,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86684,Hemophilus influenza antibdy,Lab Services,Per Unit,$15.84 ,OP,15.84,15.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86687,Htlv-i antibody,Lab Services,Per Unit,$9.09 ,OP,9.09,9.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86688,Htlv-ii antibody,Lab Services,Per Unit,$14.00 ,OP,14,14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86689,Htlv/hiv confirmj antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86692,Hepatitis delta agent antbdy,Lab Services,Per Unit,$17.16 ,OP,17.16,17.16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86694,Herpes simplex nes antbdy,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86695,Herpes simplex type 1 test,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86696,Herpes simplex type 2 test,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86698,Histoplasma antibody,Lab Services,Per Unit,$13.79 ,OP,13.79,13.79,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86701,Hiv-1antibody,Lab Services,Per Unit,$8.89 ,OP,8.89,8.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86702,Hiv-2 antibody,Lab Services,Per Unit,$13.52 ,OP,13.52,13.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86703,Hiv-1/hiv-2 1 result antbdy,Lab Services,Per Unit,$13.71 ,OP,13.71,13.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86704,Hep b core antibody total,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86705,Hep b core antibody igm,Lab Services,Per Unit,$11.77 ,OP,11.77,11.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86706,Hep b surface antibody,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86707,Hepatitis be antibody,Lab Services,Per Unit,$11.57 ,OP,11.57,11.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86708,Hepatitis a antibody,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86709,Hepatitis a igm antibody,Lab Services,Per Unit,$11.26 ,OP,11.26,11.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86710,Influenza virus antibody,Lab Services,Per Unit,$13.55 ,OP,13.55,13.55,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86711,John cunningham antibody,Lab Services,Per Unit,$16.89 ,OP,16.89,16.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86713,Legionella antibody,Lab Services,Per Unit,$15.30 ,OP,15.3,15.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86717,Leishmania antibody,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86720,Leptospira antibody,Lab Services,Per Unit,$16.20 ,OP,16.2,16.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86723,Listeria monocytogenes,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86727,Lymph choriomeningitis ab,Lab Services,Per Unit,$12.87 ,OP,12.87,12.87,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86732,Mucormycosis antibody,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86735,Mumps antibody,Lab Services,Per Unit,$13.05 ,OP,13.05,13.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86738,Mycoplasma antibody,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86741,Neisseria meningitidis,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86744,Nocardia antibody,Lab Services,Per Unit,$15.99 ,OP,15.99,15.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86747,Parvovirus antibody,Lab Services,Per Unit,$15.03 ,OP,15.03,15.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86750,Malaria antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86753,Protozoa antibody nos,Lab Services,Per Unit,$12.39 ,OP,12.39,12.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86756,Respiratory virus antibody,Lab Services,Per Unit,$15.89 ,OP,15.89,15.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86757,Rickettsia antibody,Lab Services,Per Unit,$19.35 ,OP,19.35,19.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86759,Rotavirus antibody,Lab Services,Per Unit,$18.23 ,OP,18.23,18.23,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86762,Rubella antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86765,Rubeola antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86768,Salmonella antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86771,Shigella antibody,Lab Services,Per Unit,$24.48 ,OP,24.48,24.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86774,Tetanus antibody,Lab Services,Per Unit,$14.80 ,OP,14.8,14.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86777,Toxoplasma antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86778,Toxoplasma antibody igm,Lab Services,Per Unit,$14.41 ,OP,14.41,14.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86780,Treponema pallidum,Lab Services,Per Unit,$13.24 ,OP,13.24,13.24,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86784,Trichinella antibody,Lab Services,Per Unit,$12.56 ,OP,12.56,12.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86787,Varicella-zoster antibody,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86788,West nile virus ab igm,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86789,West nile virus antibody,Lab Services,Per Unit,$14.39 ,OP,14.39,14.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86790,Virus antibody nos,Lab Services,Per Unit,$12.88 ,OP,12.88,12.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86793,Yersinia antibody,Lab Services,Per Unit,$13.19 ,OP,13.19,13.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86794,Zika virus igm antibody,Lab Services,Per Unit,$16.85 ,OP,16.85,16.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86800,Thyroglobulin antibody,Lab Services,Per Unit,$15.91 ,OP,15.91,15.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86803,Hepatitis c ab test,Lab Services,Per Unit,$14.27 ,OP,14.27,14.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86804,Hep c ab test confirm,Lab Services,Per Unit,$15.49 ,OP,15.49,15.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86805,Lymphocytotoxicity assay,Lab Services,Per Unit,$189.51 ,OP,189.51,189.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86806,Lymphocytotoxicity assay,Lab Services,Per Unit,$47.59 ,OP,47.59,47.59,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86807,Cytotoxic antibody screening,Lab Services,Per Unit,$78.65 ,OP,78.65,78.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86808,Cytotoxic antibody screening,Lab Services,Per Unit,$29.68 ,OP,29.68,29.68,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86812,Hla typing a b or c,Lab Services,Per Unit,$25.81 ,OP,25.81,25.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86813,Hla typing a b or c,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86816,Hla typing dr/dq,Lab Services,Per Unit,$30.17 ,OP,30.17,30.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86817,Hla typing dr/dq,Lab Services,Per Unit,$106.14 ,OP,106.14,106.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86821,Lymphocyte culture mixed,Lab Services,Per Unit,$36.56 ,OP,36.56,36.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86825,Hla x-math non-cytotoxic,Lab Services,Per Unit,$109.49 ,OP,109.49,109.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86826,Hla x-match noncytotoxc addl,Lab Services,Per Unit,$36.53 ,OP,36.53,36.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86828,Hla class i&ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86829,Hla class i/ii antibody qual,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86830,Hla class i phenotype qual,Lab Services,Per Unit,$95.52 ,OP,95.52,95.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86831,Hla class ii phenotype qual,Lab Services,Per Unit,$81.88 ,OP,81.88,81.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86832,Hla class i high defin qual,Lab Services,Per Unit,$323.75 ,OP,323.75,323.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86833,Hla class ii high defin qual,Lab Services,Per Unit,$325.80 ,OP,325.8,325.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86834,Hla class i semiquant panel,Lab Services,Per Unit,$357.56 ,OP,357.56,357.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86835,Hla class ii semiquant panel,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86940,Hemolysins/agglutinins auto,Lab Services,Per Unit,$8.77 ,OP,8.77,8.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,86941,Hemolysins/agglutinins,Lab Services,Per Unit,$12.11 ,OP,12.11,12.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87003,Small animal inoculation,Lab Services,Per Unit,$16.84 ,OP,16.84,16.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87015,Specimen infect agnt concntj,Lab Services,Per Unit,$6.68 ,OP,6.68,6.68,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87040,Blood culture for bacteria,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87045,Feces culture aerobic bact,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87046,Stool cultr aerobic bact ea,Lab Services,Per Unit,$9.44 ,OP,9.44,9.44,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87070,Culture othr specimn aerobic,Lab Services,Per Unit,$8.62 ,OP,8.62,8.62,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87071,Culture aerobic quant other,Lab Services,Per Unit,$9.89 ,OP,9.89,9.89,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87073,Culture bacteria anaerobic,Lab Services,Per Unit,$9.66 ,OP,9.66,9.66,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87075,Cultr bacteria except blood,Lab Services,Per Unit,$9.47 ,OP,9.47,9.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87076,Culture anaerobe ident each,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87077,Culture aerobic identify,Lab Services,Per Unit,$8.08 ,OP,8.08,8.08,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87081,Culture screen only,Lab Services,Per Unit,$6.63 ,OP,6.63,6.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87084,Culture of specimen by kit,Lab Services,Per Unit,$27.07 ,OP,27.07,27.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87086,Urine culture/colony count,Lab Services,Per Unit,$8.07 ,OP,8.07,8.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87088,Urine bacteria culture,Lab Services,Per Unit,$8.09 ,OP,8.09,8.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87101,Skin fungi culture,Lab Services,Per Unit,$7.71 ,OP,7.71,7.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87102,Fungus isolation culture,Lab Services,Per Unit,$8.41 ,OP,8.41,8.41,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87103,Blood fungus culture,Lab Services,Per Unit,$20.46 ,OP,20.46,20.46,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87106,Fungi identification yeast,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87107,Fungi identification mold,Lab Services,Per Unit,$10.32 ,OP,10.32,10.32,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87109,Mycoplasma,Lab Services,Per Unit,$15.39 ,OP,15.39,15.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87110,Chlamydia culture,Lab Services,Per Unit,$19.60 ,OP,19.6,19.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87116,Mycobacteria culture,Lab Services,Per Unit,$10.80 ,OP,10.8,10.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87118,Mycobacteric identification,Lab Services,Per Unit,$14.61 ,OP,14.61,14.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87140,Culture type immunofluoresc,Lab Services,Per Unit,$5.57 ,OP,5.57,5.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87143,Culture typing glc/hplc,Lab Services,Per Unit,$12.52 ,OP,12.52,12.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87147,Culture type immunologic,Lab Services,Per Unit,$5.18 ,OP,5.18,5.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87149,Dna/rna direct probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87150,Dna/rna amplified probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87152,Culture type pulse field gel,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87153,Dna/rna sequencing,Lab Services,Per Unit,$115.36 ,OP,115.36,115.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87158,Culture typing added method,Lab Services,Per Unit,$7.74 ,OP,7.74,7.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87164,Dark field examination,Lab Services,Per Unit,$10.74 ,OP,10.74,10.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87166,Dark field examination,Lab Services,Per Unit,$11.30 ,OP,11.3,11.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87168,Macroscopic exam arthropod,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87169,Macroscopic exam parasite,Lab Services,Per Unit,$4.31 ,OP,4.31,4.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87172,Pinworm exam,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87176,Tissue homogenization cultr,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87177,Ova and parasites smears,Lab Services,Per Unit,$8.90 ,OP,8.9,8.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87181,Microbe susceptible diffuse,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87184,Microbe susceptible disk,Lab Services,Per Unit,$7.48 ,OP,7.48,7.48,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87185,Microbe susceptible enzyme,Lab Services,Per Unit,$4.75 ,OP,4.75,4.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87186,Microbe susceptible mic,Lab Services,Per Unit,$8.65 ,OP,8.65,8.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87187,Microbe susceptible mlc,Lab Services,Per Unit,$40.17 ,OP,40.17,40.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87188,Microbe suscept macrobroth,Lab Services,Per Unit,$6.64 ,OP,6.64,6.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87190,Microbe suscept mycobacteri,Lab Services,Per Unit,$7.31 ,OP,7.31,7.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87197,Bactericidal level serum,Lab Services,Per Unit,$15.02 ,OP,15.02,15.02,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87205,Smear gram stain,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87206,Smear fluorescent/acid stai,Lab Services,Per Unit,$5.39 ,OP,5.39,5.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87207,Smear special stain,Lab Services,Per Unit,$5.99 ,OP,5.99,5.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87209,Smear complex stain,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87210,Smear wet mount saline/ink,Lab Services,Per Unit,$5.82 ,OP,5.82,5.82,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87220,Tissue exam for fungi,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87230,Assay toxin or antitoxin,Lab Services,Per Unit,$19.74 ,OP,19.74,19.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87250,Virus inoculate eggs/animal,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87252,Virus inoculation tissue,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87253,Virus inoculate tissue addl,Lab Services,Per Unit,$20.20 ,OP,20.2,20.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87254,Virus inoculation shell via,Lab Services,Per Unit,$19.56 ,OP,19.56,19.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87255,Genet virus isolate hsv,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87260,Adenovirus ag if,Lab Services,Per Unit,$14.43 ,OP,14.43,14.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87265,Pertussis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87267,Enterovirus antibody dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87269,Giardia ag if,Lab Services,Per Unit,$13.61 ,OP,13.61,13.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87270,Chlamydia trachomatis ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87271,Cytomegalovirus dfa,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87272,Cryptosporidium ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87273,Herpes simplex 2 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87274,Herpes simplex 1 ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87275,Influenza b ag if,Lab Services,Per Unit,$12.25 ,OP,12.25,12.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87276,Influenza a ag if,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87278,Legion pneumophilia ag if,Lab Services,Per Unit,$15.60 ,OP,15.6,15.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87279,Parainfluenza ag if,Lab Services,Per Unit,$16.43 ,OP,16.43,16.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87280,Respiratory syncytial ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87281,Pneumocystis carinii ag if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87283,Rubeola ag if,Lab Services,Per Unit,$60.80 ,OP,60.8,60.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87285,Treponema pallidum ag if,Lab Services,Per Unit,$12.18 ,OP,12.18,12.18,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87290,Varicella zoster ag if,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87299,Antibody detection nos if,Lab Services,Per Unit,$16.10 ,OP,16.1,16.1,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87300,Ag detection polyval if,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87301,Adenovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87305,Aspergillus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87320,Chylmd trach ag ia,Lab Services,Per Unit,$15.00 ,OP,15,15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87324,Clostridium ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87327,Cryptococcus neoform ag ia,Lab Services,Per Unit,$13.42 ,OP,13.42,13.42,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87328,Cryptosporidium ag ia,Lab Services,Per Unit,$13.82 ,OP,13.82,13.82,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87329,Giardia ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87332,Cytomegalovirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87335,E coli 0157 ag ia,Lab Services,Per Unit,$12.66 ,OP,12.66,12.66,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87336,Entamoeb hist dispr ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87337,Entamoeb hist group ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87338,Hpylori stool ag ia,Lab Services,Per Unit,$14.38 ,OP,14.38,14.38,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87339,H pylori ag ia,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87340,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87341,Hepatitis b surface ag ia,Lab Services,Per Unit,$10.33 ,OP,10.33,10.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87350,Hepatitis be ag ia,Lab Services,Per Unit,$11.53 ,OP,11.53,11.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87380,Hepatitis delta agent ag ia,Lab Services,Per Unit,$18.36 ,OP,18.36,18.36,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87385,Histoplasma capsul ag ia,Lab Services,Per Unit,$13.25 ,OP,13.25,13.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87389,Hiv-1 ag w/hiv-1&2 ab ag ia,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87390,Hiv-1 ag ia,Lab Services,Per Unit,$24.06 ,OP,24.06,24.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87391,Hiv-2 ag ia,Lab Services,Per Unit,$21.90 ,OP,21.9,21.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87400,Influenza a/b each ag ia,Lab Services,Per Unit,$14.13 ,OP,14.13,14.13,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87420,Resp syncytial virus ag ia,Lab Services,Per Unit,$13.91 ,OP,13.91,13.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87425,Rotavirus ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87427,Shiga-like toxin ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87430,Strep a ag ia,Lab Services,Per Unit,$16.81 ,OP,16.81,16.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87449,Nos each organism ag ia,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87451,Polyvalent mult org ea ag ia,Lab Services,Per Unit,$10.51 ,OP,10.51,10.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87471,Bartonella dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87472,Bartonella dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87475,Lyme dis dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87476,Lyme dis dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87480,Candida dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87481,Candida dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87482,Candida dna quant,Lab Services,Per Unit,$55.74 ,OP,55.74,55.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87483,Cns dna amp probe type 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87485,Chylmd pneum dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87486,Chylmd pneum dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87487,Chylmd pneum dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87490,Chylmd trach dna dir probe,Lab Services,Per Unit,$22.75 ,OP,22.75,22.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87491,Chylmd trach dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87492,Chylmd trach dna quant,Lab Services,Per Unit,$53.47 ,OP,53.47,53.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87493,C diff amplified probe,Lab Services,Per Unit,$37.27 ,OP,37.27,37.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87495,Cytomeg dna dir probe,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87496,Cytomeg dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87497,Cytomeg dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87498,Enterovirus probe&revrs trns,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87500,Vanomycin dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87501,Influenza dna amp prob 1+,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87502,Influenza dna amp probe,Lab Services,Per Unit,$95.80 ,OP,95.8,95.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87503,Influenza dna amp prob addl,Lab Services,Per Unit,$29.22 ,OP,29.22,29.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87505,Nfct agent detection gi,Lab Services,Per Unit,$128.29 ,OP,128.29,128.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87506,Iadna-dna/rna probe tq 6-11,Lab Services,Per Unit,$262.99 ,OP,262.99,262.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87507,Iadna-dna/rna probe tq 12-25,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87510,Gardner vag dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87511,Gardner vag dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87512,Gardner vag dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87516,Hepatitis b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87517,Hepatitis b dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87520,Hepatitis c rna dir probe,Lab Services,Per Unit,$31.22 ,OP,31.22,31.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87521,Hepatitis c probe&rvrs trnsc,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87522,Hepatitis c revrs trnscrpj,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87525,Hepatitis g dna dir probe,Lab Services,Per Unit,$29.80 ,OP,29.8,29.8,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87526,Hepatitis g dna amp probe,Lab Services,Per Unit,$39.26 ,OP,39.26,39.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87527,Hepatitis g dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87528,Hsv dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87529,Hsv dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87530,Hsv dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87531,Hhv-6 dna dir probe,Lab Services,Per Unit,$58.00 ,OP,58,58,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87532,Hhv-6 dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87533,Hhv-6 dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87534,Hiv-1 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87535,Hiv-1 probe&reverse trnscrpj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87536,Hiv-1 quant&revrse trnscrpj,Lab Services,Per Unit,$85.10 ,OP,85.1,85.1,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87537,Hiv-2 dna dir probe,Lab Services,Per Unit,$21.92 ,OP,21.92,21.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87538,Hiv-2 probe&revrse trnscripj,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87539,Hiv-2 quant&revrse trnscripj,Lab Services,Per Unit,$58.62 ,OP,58.62,58.62,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87540,Legion pneumo dna dir prob,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87541,Legion pneumo dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87542,Legion pneumo dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87550,Mycobacteria dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87551,Mycobacteria dna amp probe,Lab Services,Per Unit,$48.24 ,OP,48.24,48.24,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87552,Mycobacteria dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87555,M.tuberculo dna dir probe,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87556,M.tuberculo dna amp probe,Lab Services,Per Unit,$41.68 ,OP,41.68,41.68,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87557,M.tuberculo dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87560,M.avium-intra dna dir prob,Lab Services,Per Unit,$27.29 ,OP,27.29,27.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87561,M.avium-intra dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87562,M.avium-intra dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87563,M. genitalium amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87580,M.pneumon dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87581,M.pneumon dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87582,M.pneumon dna quant,Lab Services,Per Unit,$302.62 ,OP,302.62,302.62,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87590,N.gonorrhoeae dna dir prob,Lab Services,Per Unit,$26.88 ,OP,26.88,26.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87591,N.gonorrhoeae dna amp prob,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87592,N.gonorrhoeae dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87623,Hpv low-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87624,Hpv high-risk types,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87625,Hpv types 16 & 18 only,Lab Services,Per Unit,$40.55 ,OP,40.55,40.55,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87631,Resp virus 3-5 targets,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87632,Resp virus 6-11 targets,Lab Services,Per Unit,$218.06 ,OP,218.06,218.06,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87633,Resp virus 12-25 targets,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87634,Rsv dna/rna amp probe,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87640,Staph a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87641,Mr-staph dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87650,Strep a dna dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87651,Strep a dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87652,Strep a dna quant,Lab Services,Per Unit,$41.76 ,OP,41.76,41.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87653,Strep b dna amp probe,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87660,Trichomonas vagin dir probe,Lab Services,Per Unit,$20.05 ,OP,20.05,20.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87661,Trichomonas vaginalis amplif,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87662,Zika virus dna/rna amp probe,Lab Services,Per Unit,$51.31 ,OP,51.31,51.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87797,Detect agent nos dna dir,Lab Services,Per Unit,$30.03 ,OP,30.03,30.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87798,Detect agent nos dna amp,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87799,Detect agent nos dna quant,Lab Services,Per Unit,$42.84 ,OP,42.84,42.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87800,Detect agnt mult dna direc,Lab Services,Per Unit,$43.67 ,OP,43.67,43.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87801,Detect agnt mult dna ampli,Lab Services,Per Unit,$70.20 ,OP,70.2,70.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87802,Strep b assay w/optic,Lab Services,Per Unit,$12.73 ,OP,12.73,12.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87803,Clostridium toxin a w/optic,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87804,Influenza assay w/optic,Lab Services,Per Unit,$16.55 ,OP,16.55,16.55,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87806,Hiv w/hiv1&2 antb w/optic,Lab Services,Per Unit,$32.77 ,OP,32.77,32.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87807,Rsv assay w/optic,Lab Services,Per Unit,$13.10 ,OP,13.1,13.1,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87808,Trichomonas assay w/optic,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87809,Adenovirus assay w/optic,Lab Services,Per Unit,$21.76 ,OP,21.76,21.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87810,Chylmd trach assay w/optic,Lab Services,Per Unit,$35.29 ,OP,35.29,35.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87850,N. gonorrhoeae assay w/optic,Lab Services,Per Unit,$24.56 ,OP,24.56,24.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87880,Strep a assay w/optic,Lab Services,Per Unit,$16.53 ,OP,16.53,16.53,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87899,Agent nos assay w/optic,Lab Services,Per Unit,$16.07 ,OP,16.07,16.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87900,Phenotype infect agent drug,Lab Services,Per Unit,$130.35 ,OP,130.35,130.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87901,Genotype dna hiv reverse t,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87902,Genotype dna/rna hep c,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87903,Phenotype dna hiv w/culture,Lab Services,Per Unit,$488.66 ,OP,488.66,488.66,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87904,Phenotype dna hiv w/clt add,Lab Services,Per Unit,$26.07 ,OP,26.07,26.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87905,Sialidase enzyme assay,Lab Services,Per Unit,$12.22 ,OP,12.22,12.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87906,Genotype dna/rna hiv,Lab Services,Per Unit,$128.73 ,OP,128.73,128.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87910,Genotype cytomegalovirus,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,87912,Genotype dna hepatitis b,Lab Services,Per Unit,$257.45 ,OP,257.45,257.45,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88130,Sex chromatin identification,Lab Services,Per Unit,$17.98 ,OP,17.98,17.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88140,Sex chromatin identification,Lab Services,Per Unit,$7.99 ,OP,7.99,7.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88142,Cytopath c/v thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88143,Cytopath c/v thin layer redo,Lab Services,Per Unit,$23.04 ,OP,23.04,23.04,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88147,Cytopath c/v automated,Lab Services,Per Unit,$50.56 ,OP,50.56,50.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88148,Cytopath c/v auto rescreen,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88150,Cytopath c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88152,Cytopath c/v auto redo,Lab Services,Per Unit,$27.64 ,OP,27.64,27.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88153,Cytopath c/v redo,Lab Services,Per Unit,$24.03 ,OP,24.03,24.03,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88155,Cytopath c/v index add-on,Lab Services,Per Unit,$14.65 ,OP,14.65,14.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88164,Cytopath tbs c/v manual,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88165,Cytopath tbs c/v redo,Lab Services,Per Unit,$42.22 ,OP,42.22,42.22,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88166,Cytopath tbs c/v auto redo,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88167,Cytopath tbs c/v select,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88174,Cytopath c/v auto in fluid,Lab Services,Per Unit,$25.37 ,OP,25.37,25.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88175,Cytopath c/v auto fluid redo,Lab Services,Per Unit,$26.61 ,OP,26.61,26.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88230,Tissue culture lymphocyte,Lab Services,Per Unit,$116.49 ,OP,116.49,116.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88233,Tissue culture skin/biopsy,Lab Services,Per Unit,$140.73 ,OP,140.73,140.73,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88235,Tissue culture placenta,Lab Services,Per Unit,$150.30 ,OP,150.3,150.3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88237,Tissue culture bone marrow,Lab Services,Per Unit,$143.75 ,OP,143.75,143.75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88239,Tissue culture tumor,Lab Services,Per Unit,$147.52 ,OP,147.52,147.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88240,Cell cryopreserve/storage,Lab Services,Per Unit,$13.07 ,OP,13.07,13.07,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88241,Frozen cell preparation,Lab Services,Per Unit,$12.09 ,OP,12.09,12.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88245,Chromosome analysis 20-25,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88248,Chromosome analysis 50-100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88249,Chromosome analysis 100,Lab Services,Per Unit,$173.17 ,OP,173.17,173.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88261,Chromosome analysis 5,Lab Services,Per Unit,$264.34 ,OP,264.34,264.34,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88262,Chromosome analysis 15-20,Lab Services,Per Unit,$125.49 ,OP,125.49,125.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88263,Chromosome analysis 45,Lab Services,Per Unit,$150.29 ,OP,150.29,150.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88264,Chromosome analysis 20-25,Lab Services,Per Unit,$144.61 ,OP,144.61,144.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88267,Chromosome analys placenta,Lab Services,Per Unit,$188.57 ,OP,188.57,188.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88269,Chromosome analys amniotic,Lab Services,Per Unit,$173.66 ,OP,173.66,173.66,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88271,Cytogenetics dna probe,Lab Services,Per Unit,$21.42 ,OP,21.42,21.42,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88272,Cytogenetics 3-5,Lab Services,Per Unit,$40.70 ,OP,40.7,40.7,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88273,Cytogenetics 10-30,Lab Services,Per Unit,$34.81 ,OP,34.81,34.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88274,Cytogenetics 25-99,Lab Services,Per Unit,$42.38 ,OP,42.38,42.38,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88275,Cytogenetics 100-300,Lab Services,Per Unit,$51.19 ,OP,51.19,51.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88280,Chromosome karyotype study,Lab Services,Per Unit,$33.47 ,OP,33.47,33.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88283,Chromosome banding study,Lab Services,Per Unit,$68.60 ,OP,68.6,68.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88285,Chromosome count additional,Lab Services,Per Unit,$26.91 ,OP,26.91,26.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88289,Chromosome study additional,Lab Services,Per Unit,$34.43 ,OP,34.43,34.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88720,Bilirubin total transcut,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88738,Hgb quant transcutaneous,Lab Services,Per Unit,$5.02 ,OP,5.02,5.02,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88740,Transcutaneous carboxyhb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,88741,Transcutaneous methb,Lab Services,Per Unit,$9.37 ,OP,9.37,9.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89050,Body fluid cell count,Lab Services,Per Unit,$4.72 ,OP,4.72,4.72,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89051,Body fluid cell count,Lab Services,Per Unit,$5.60 ,OP,5.6,5.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89055,Leukocyte assessment fecal,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89060,Exam synovial fluid crystals,Lab Services,Per Unit,$7.33 ,OP,7.33,7.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89125,Specimen fat stain,Lab Services,Per Unit,$5.88 ,OP,5.88,5.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89160,Exam feces for meat fibers,Lab Services,Per Unit,$4.85 ,OP,4.85,4.85,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89190,Nasal smear for eosinophils,Lab Services,Per Unit,$5.79 ,OP,5.79,5.79,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89300,Semen analysis w/huhner,Lab Services,Per Unit,$9.84 ,OP,9.84,9.84,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89310,Semen analysis w/count,Lab Services,Per Unit,$8.61 ,OP,8.61,8.61,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89320,Semen anal vol/count/mot,Lab Services,Per Unit,$12.31 ,OP,12.31,12.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89321,Semen anal sperm detection,Lab Services,Per Unit,$12.05 ,OP,12.05,12.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89322,Semen anal strict criteria,Lab Services,Per Unit,$15.50 ,OP,15.5,15.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89325,Sperm antibody test,Lab Services,Per Unit,$10.67 ,OP,10.67,10.67,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89329,Sperm evaluation test,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89330,Evaluation cervical mucus,Lab Services,Per Unit,$10.38 ,OP,10.38,10.38,,,,,,,,,,,,
United Healthcare VA PC3,CPT,89331,Retrograde ejaculation anal,Lab Services,Per Unit,$19.59 ,OP,19.59,19.59,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0001U,Rbc dna hea 35 ag 11 bld grp,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0002M,Liver dis 10 assays w/ash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0002U,Onc clrct 3 ur metab alg plp,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0003M,Liver dis 10 assays w/nash,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0003U,Onc ovar 5 prtn ser alg scor,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0004M,Scoliosis dna alys,Lab Services,Per Unit,$79.00 ,OP,79,79,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0005U,Onco prst8 3 gene ur alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0006M,Onc hep gene risk classifier,Lab Services,Per Unit,$150.00 ,OP,150,150,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0007M,Onc gastro 51 gene nomogram,Lab Services,Per Unit,$375.00 ,OP,375,375,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0007U,Rx test prsmv ur w/def conf,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0008U,Hpylori detcj abx rstnc dna,Lab Services,Per Unit,$597.91 ,OP,597.91,597.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0009U,Onc brst ca erbb2 amp/nonamp,Lab Services,Per Unit,$107.00 ,OP,107,107,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0010U,Nfct ds strn typ whl gen seq,Lab Services,Per Unit,$427.26 ,OP,427.26,427.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0011M,Onc prst8 ca mrna 12 gen alg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0011U,Rx mntr lc-ms/ms oral fluid,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0012M,Onc mrna 5 gen rsk urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0012U,Germln do gene reargmt detcj,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0013M,Onc mrna 5 gen recr urthl ca,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0013U,Onc sld org neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0014M,Liver ds alys 3 bmrk srm alg,Lab Services,Per Unit,$176.19 ,OP,176.19,176.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0014U,Hem hmtlmf neo gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0016U,Onc hmtlmf neo rna bcr/abl1,Lab Services,Per Unit,$163.96 ,OP,163.96,163.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0017U,Onc hmtlmf neo jak2 mut dna,Lab Services,Per Unit,$91.66 ,OP,91.66,91.66,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0018U,Onc thyr 10 microrna seq alg,Lab Services,Per Unit,"$3,002.09 ",OP,"3,002.09","3,002.09",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0019U,Onc rna tiss predict alg,Lab Services,Per Unit,"$3,675.00 ",OP,"3,675.00","3,675.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0021U,Onc prst8 detcj 8 autoantb,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0022U,Trgt gen seq dna&rna 23 gene,Lab Services,Per Unit,"$1,950.00 ",OP,"1,950.00","1,950.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0023U,Onc aml dna detcj/nondetcj,Lab Services,Per Unit,$248.51 ,OP,248.51,248.51,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0024U,Glyca nuc mr spectrsc quan,Lab Services,Per Unit,$34.19 ,OP,34.19,34.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0025U,Tenofovir liq chrom ur quan,Lab Services,Per Unit,$85.77 ,OP,85.77,85.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0026U,Onc thyr dna&mrna 112 genes,Lab Services,Per Unit,"$3,600.00 ",OP,"3,600.00","3,600.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0027U,Jak2 gene trgt seq alys,Lab Services,Per Unit,$121.91 ,OP,121.91,121.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0029U,Rx metab advrs trgt seq alys,Lab Services,Per Unit,$742.27 ,OP,742.27,742.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0030U,Rx metab warf trgt seq alys,Lab Services,Per Unit,$134.13 ,OP,134.13,134.13,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0031U,Cyp1a2 gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0032U,Comt gene,Lab Services,Per Unit,$174.81 ,OP,174.81,174.81,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0033U,Htr2a htr2c genes,Lab Services,Per Unit,$349.62 ,OP,349.62,349.62,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0034U,Tpmt nudt15 genes,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0035U,Neuro csf prion prtn qual,Lab Services,Per Unit,$540.99 ,OP,540.99,540.99,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0036U,Xome tum & nml spec seq alys,Lab Services,Per Unit,"$4,780.00 ",OP,"4,780.00","4,780.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0037U,Trgt gen seq dna 324 genes,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0038U,Vitamin d srm microsamp quan,Lab Services,Per Unit,$29.60 ,OP,29.6,29.6,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0039U,Dna antb 2strand hi avidity,Lab Services,Per Unit,$13.74 ,OP,13.74,13.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0040U,Bcr/abl1 gene major bp quan,Lab Services,Per Unit,$409.90 ,OP,409.9,409.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0041U,B brgdrferi antb 5 prtn igm,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0042U,B brgdrferi antb 12 prtn igg,Lab Services,Per Unit,$17.21 ,OP,17.21,17.21,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0043U,Tbrf b grp antb 4 prtn igm,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0044U,Tbrf b grp antb 4 prtn igg,Lab Services,Per Unit,$14.86 ,OP,14.86,14.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0045U,Onc brst dux carc is 12 gene,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0046U,Flt3 gene itd variants quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0047U,Onc prst8 mrna 17 gene alg,Lab Services,Per Unit,"$3,873.00 ",OP,"3,873.00","3,873.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0048U,Onc sld org neo dna 468 gene,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0049U,Npm1 gene analysis quan,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0050U,Trgt gen seq dna 194 genes,Lab Services,Per Unit,"$2,916.60 ",OP,"2,916.60","2,916.60",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0051U,Rx mntr lc-ms/ms ur 31 pnl,Lab Services,Per Unit,$193.71 ,OP,193.71,193.71,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0052U,Lpoprtn bld w/5 maj classes,Lab Services,Per Unit,$33.86 ,OP,33.86,33.86,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0053U,Onc prst8 ca fish alys 4 gen,Lab Services,Per Unit,"$2,030.00 ",OP,"2,030.00","2,030.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0054U,Rx mntr 14+ drugs & sbsts,Lab Services,Per Unit,$148.96 ,OP,148.96,148.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0055U,Card hrt trnspl 96 dna seq,Lab Services,Per Unit,"$3,240.00 ",OP,"3,240.00","3,240.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0056U,Hem aml dna gene reargmt,Lab Services,Per Unit,"$2,515.60 ",OP,"2,515.60","2,515.60",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0058U,Onc merkel cll carc srm quan,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0059U,Onc merkel cll carc srm +/-,Lab Services,Per Unit,$322.96 ,OP,322.96,322.96,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0060U,Twn zyg gen seq alys chrms2,Lab Services,Per Unit,$759.05 ,OP,759.05,759.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0061U,Tc meas 5 bmrk sfdi m-s alys,Lab Services,Per Unit,$25.10 ,OP,25.1,25.1,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0062U,Ai sle igg&igm alys 80 bmrk,Lab Services,Per Unit,$380.72 ,OP,380.72,380.72,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0063U,Neuro autism 32 amines alg,Lab Services,Per Unit,$750.00 ,OP,750,750,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0064U,Antb tp total&rpr ia qual,Lab Services,Per Unit,$31.33 ,OP,31.33,31.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0065U,Syfls tst nontreponemal antb,Lab Services,Per Unit,$18.09 ,OP,18.09,18.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0066U,Pamg-1 ia cervico-vag fluid,Lab Services,Per Unit,$15.29 ,OP,15.29,15.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0067U,Onc brst imhchem prfl 4 bmrk,Lab Services,Per Unit,"$1,897.00 ",OP,"1,897.00","1,897.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0068U,Candida species pnl amp prb,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0069U,Onc clrct microrna mir-31-3p,Lab Services,Per Unit,$380.00 ,OP,380,380,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0070U,Cyp2d6 gen com&slct rar vrnt,Lab Services,Per Unit,$676.37 ,OP,676.37,676.37,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0071U,Cyp2d6 full gene sequence,Lab Services,Per Unit,$600.00 ,OP,600,600,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0072U,Cyp2d6 gen cyp2d6-2d7 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0073U,Cyp2d6 gen cyp2d7-2d6 hybrid,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0074U,Cyp2d6 nonduplicated gene,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0075U,Cyp2d6 5' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0076U,Cyp2d6 3' gene dup/mlt,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0077U,Ig paraprotein qual bld/ur,Lab Services,Per Unit,$43.43 ,OP,43.43,43.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0078U,Pain mgt opi use gnotyp pnl,Lab Services,Per Unit,$450.91 ,OP,450.91,450.91,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0080U,Onc lng 5 clin rsk factr alg,Lab Services,Per Unit,"$3,520.00 ",OP,"3,520.00","3,520.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0082U,Rx test def 90+ rx/sbsts ur,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0083U,Onc rspse chemo cntrst tomog,Lab Services,Per Unit,$167.35 ,OP,167.35,167.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0084U,Rbc dna gnotyp 10 bld groups,Lab Services,Per Unit,$720.00 ,OP,720,720,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0086U,Nfct ds bact&fng org id 6+,Lab Services,Per Unit,$200.00 ,OP,200,200,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0087U,Crd hrt trnspl mrna 1283 gen,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0088U,Trnsplj kdn algrft rej 1494,Lab Services,Per Unit,"$3,159.42 ",OP,"3,159.42","3,159.42",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0089U,Onc mlnma prame & linc00518,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0090U,Onc cutan mlnma mrna 23 gene,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0092U,Onc lng 3 prtn bmrk plsm alg,Lab Services,Per Unit,"$2,488.00 ",OP,"2,488.00","2,488.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0093U,Rx mntr 65 com drugs urine,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0094U,Genome rapid sequence alys,Lab Services,Per Unit,"$7,582.20 ",OP,"7,582.20","7,582.20",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0095U,Inflm ee elisa alys alg,Lab Services,Per Unit,$771.98 ,OP,771.98,771.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0096U,Hpv hi risk types male urine,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0097U,Gi pathogen 22 targets,Lab Services,Per Unit,$363.04 ,OP,363.04,363.04,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0105U,Neph ckd mult eclia tum nec,Lab Services,Per Unit,$950.00 ,OP,950,950,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0106U,Gstr emptg 7 timed brth spec,Lab Services,Per Unit,$874.49 ,OP,874.49,874.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0107U,C diff tox ag detcj ia stool,Lab Services,Per Unit,$16.00 ,OP,16,16,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0108U,Gi barrett esoph 9 prtn bmrk,Lab Services,Per Unit,"$2,513.25 ",OP,"2,513.25","2,513.25",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0109U,Id aspergillus dna 4 species,Lab Services,Per Unit,$142.63 ,OP,142.63,142.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0110U,Rx mntr 1+oral onc rx&sbsts,Lab Services,Per Unit,$27.11 ,OP,27.11,27.11,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0111U,Onc colon ca kras&nras alys,Lab Services,Per Unit,$682.29 ,OP,682.29,682.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0112U,Iadi 16s&18s rrna genes,Lab Services,Per Unit,$356.13 ,OP,356.13,356.13,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0113U,Onc prst8 pca3&tmprss2-erg,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0114U,Gi barretts esoph vim&ccna1,Lab Services,Per Unit,"$1,938.01 ",OP,"1,938.01","1,938.01",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0115U,Respir iadna 18 viral&2 bact,Lab Services,Per Unit,$275.35 ,OP,275.35,275.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0116U,Rx mntr nzm ia 35+oral flu,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0117U,Pain mgmt 11 endogenous anal,Lab Services,Per Unit,$840.65 ,OP,840.65,840.65,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0118U,Trnsplj don-drv cll-fr dna,Lab Services,Per Unit,"$2,753.25 ",OP,"2,753.25","2,753.25",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0119U,Crd ceramides liq chrom plsm,Lab Services,Per Unit,$83.76 ,OP,83.76,83.76,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0120U,Onc b cll lymphm mrna 58 gen,Lab Services,Per Unit,"$2,510.21 ",OP,"2,510.21","2,510.21",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0121U,Sc dis vcam-1 whole blood,Lab Services,Per Unit,$509.20 ,OP,509.2,509.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0122U,Sc dis p-selectin whl blood,Lab Services,Per Unit,$526.23 ,OP,526.23,526.23,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0123U,Mchnl fragility rbc prflg,Lab Services,Per Unit,$357.63 ,OP,357.63,357.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0130U,Hered colon ca do mrna pnl,Lab Services,Per Unit,$584.90 ,OP,584.9,584.9,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0131U,Hered brst ca rltd do pnl 13,Lab Services,Per Unit,$710.00 ,OP,710,710,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0132U,Hered ova ca rltd do pnl 17,Lab Services,Per Unit,$741.64 ,OP,741.64,741.64,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0133U,Hered prst8 ca rltd do 11,Lab Services,Per Unit,$690.29 ,OP,690.29,690.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0134U,Hered pan ca mrna pnl 18 gen,Lab Services,Per Unit,$748.39 ,OP,748.39,748.39,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0135U,Hered gyn ca mrna pnl 12 gen,Lab Services,Per Unit,$700.56 ,OP,700.56,700.56,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0136U,Atm mrna seq alys,Lab Services,Per Unit,$407.43 ,OP,407.43,407.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0137U,Palb2 mrna seq alys,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0138U,Brca1 brca2 mrna seq alys,Lab Services,Per Unit,$468.33 ,OP,468.33,468.33,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0145U,Drug assay 65+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0146U,Drug assay 80+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0147U,Drug assay 85+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0148U,Drug assay 100+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0149U,Drug assay 60+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0150U,Drug assay 120+ rx/metablt,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0154U,Onc urthl ca rna fgfr3 gene,Lab Services,Per Unit,$482.14 ,OP,482.14,482.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0155U,Onc brst ca dna pik3ca gene,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0166U,Liver ds 10 biochem asy srm,Lab Services,Per Unit,$503.40 ,OP,503.4,503.4,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0167U,Chornc gonadotropin hcg ia,Lab Services,Per Unit,$7.52 ,OP,7.52,7.52,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0169U,Nudt15&tpmt gene com vrnt,Lab Services,Per Unit,$466.17 ,OP,466.17,466.17,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0170U,Neuro asd rna next gen seq,Lab Services,Per Unit,"$1,755.00 ",OP,"1,755.00","1,755.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0172U,Onc sld tum alys brca1 brca2,Lab Services,Per Unit,"$3,030.00 ",OP,"3,030.00","3,030.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0176U,Cdtb&vinculin igg antb ia,Lab Services,Per Unit,$64.19 ,OP,64.19,64.19,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0177U,Onc brst ca dna pik3ca 11,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0181U,Co gnotyp aqp1 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0182U,Crom gnotyp cd55 exons 1-10,Lab Services,Per Unit,$301.35 ,OP,301.35,301.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0183U,Di gnotyp slc4a1 exon 19,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0184U,Do gnotyp art4 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0185U,Fut1 gnotyp fut1 exon 4,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0186U,Fut2 gnotyp fut2 exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0187U,Fy gnotyp ackr1 exons 1-2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0188U,Ge gnotyp gypc exons 1-4,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0189U,Gypa gnotyp ntrns 1 5 exon 2,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0190U,Gypb gnotyp ntrns 1 5 seux 3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0191U,In gnotyp cd44 exons 2 3 6,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0192U,Jk gnotyp slc14a1 exon 9,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0193U,Jr gnotyp abcg2 exons 2-26,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0194U,Kel gnotyp kel exon 8,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0195U,Klf1 targeted sequencing,Lab Services,Per Unit,$375.25 ,OP,375.25,375.25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0196U,Lu gnotyp bcam exon 3,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0197U,Lw gnotyp icam4 exon 1,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0198U,Rhd&rhce gntyp rhd1-10&rhce5,Lab Services,Per Unit,$282.88 ,OP,282.88,282.88,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0199U,Sc gnotyp ermap exons 4 12,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0200U,Xk gnotyp xk exons 1-3,Lab Services,Per Unit,$274.83 ,OP,274.83,274.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0201U,Yt gnotyp ache exon 2,Lab Services,Per Unit,$185.20 ,OP,185.2,185.2,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0202U,Nfct ds 22 trgt sars-cov-2,Lab Services,Per Unit,$416.78 ,OP,416.78,416.78,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0203U,Ai ibd mrna xprsn prfl 17,Lab Services,Per Unit,$760.00 ,OP,760,760,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0204U,Onc thyr mrna xprsn alys 593,Lab Services,Per Unit,"$2,919.60 ",OP,"2,919.60","2,919.60",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0205U,Oph amd alys 3 gene variants,Lab Services,Per Unit,$47.00 ,OP,47,47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0210U,Syphilis tst antb ia quan,Lab Services,Per Unit,$18.63 ,OP,18.63,18.63,,,,,,,,,,,,
United Healthcare VA PC3,CPT,0218U,Neuro musc dys dmd seq alys,Lab Services,Per Unit,"$2,279.00 ",OP,"2,279.00","2,279.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0239U,Trgt gen seq alys pnl 311+,Lab Services,Per Unit,"$3,500.00 ",OP,"3,500.00","3,500.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,0242U,Trgt gen seq alys pnl 55-74,Lab Services,Per Unit,"$5,000.00 ",OP,"5,000.00","5,000.00",,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0027,Semen analysis,Lab Services,Per Unit,$6.50 ,OP,6.5,6.5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0103,Psa screening,Lab Services,Per Unit,$19.31 ,OP,19.31,19.31,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0123,Screen cerv/vag thin layer,Lab Services,Per Unit,$20.26 ,OP,20.26,20.26,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0143,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$27.05 ,OP,27.05,27.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0144,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$43.97 ,OP,43.97,43.97,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0145,Scr c/v cyto-thinlayer-rescr,Lab Services,Per Unit,$26.49 ,OP,26.49,26.49,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0147,Scr c/v cyto- automated sys,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0148,Scr c/v cyto- autosys- rescr,Lab Services,Per Unit,$31.94 ,OP,31.94,31.94,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0306,Cbc/diffwbc w/o platelet,Lab Services,Per Unit,$7.77 ,OP,7.77,7.77,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0307,Cbc without platelet,Lab Services,Per Unit,$6.47 ,OP,6.47,6.47,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0328,Fecal blood scrn immunoassay,Lab Services,Per Unit,$18.05 ,OP,18.05,18.05,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0432,Eia hiv-1/hiv-2 screen,Lab Services,Per Unit,$19.57 ,OP,19.57,19.57,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0433,Elisa hiv-1/hiv-2 screen,Lab Services,Per Unit,$18.29 ,OP,18.29,18.29,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0435,Oral hiv-1/hiv-2 screen,Lab Services,Per Unit,$11.98 ,OP,11.98,11.98,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0471,Ven blood coll snf/hha,Lab Services,Per Unit,$5.00 ,OP,5,5,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0472,Hep c screen high risk/other,Lab Services,Per Unit,$46.35 ,OP,46.35,46.35,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0475,Hiv combination assay,Lab Services,Per Unit,$24.08 ,OP,24.08,24.08,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0476,Hpv combo assay ca screen,Lab Services,Per Unit,$35.09 ,OP,35.09,35.09,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0480,Drug test def 1-7 classes,Lab Services,Per Unit,$114.43 ,OP,114.43,114.43,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0481,Drug test def 8-14 classes,Lab Services,Per Unit,$156.59 ,OP,156.59,156.59,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0482,Drug test def 15-21 classes,Lab Services,Per Unit,$198.74 ,OP,198.74,198.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0483,Drug test def 22+ classes,Lab Services,Per Unit,$246.92 ,OP,246.92,246.92,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0499,Hepb screen high risk indiv,Lab Services,Per Unit,$28.27 ,OP,28.27,28.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,G0659,Drug test def simple all cl,Lab Services,Per Unit,$62.14 ,OP,62.14,62.14,,,,,,,,,,,,
United Healthcare VA PC3,CPT,P2028,Cephalin floculation test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,P2029,Congo red blood test,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,P2033,Blood thymol turbidity,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,P2038,Blood mucoprotein,Lab Services,Per Unit,$4.95 ,OP,4.95,4.95,,,,,,,,,,,,
United Healthcare VA PC3,CPT,P3000,Screen pap by tech w md supv,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,P9612,Catheterize for urine spec,Lab Services,Per Unit,$3.00 ,OP,3,3,,,,,,,,,,,,
United Healthcare VA PC3,CPT,Q0111,Wet mounts/ w preparations,Lab Services,Per Unit,$15.15 ,OP,15.15,15.15,,,,,,,,,,,,
United Healthcare VA PC3,CPT,Q0112,Potassium hydroxide preps,Lab Services,Per Unit,$5.83 ,OP,5.83,5.83,,,,,,,,,,,,
United Healthcare VA PC3,CPT,Q0113,Pinworm examinations,Lab Services,Per Unit,$4.27 ,OP,4.27,4.27,,,,,,,,,,,,
United Healthcare VA PC3,CPT,Q0114,Fern test,Lab Services,Per Unit,$9.74 ,OP,9.74,9.74,,,,,,,,,,,,
United Healthcare VA PC3,CPT,Q0115,Post-coital mucous exam,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
United Healthcare VA PC3,CPT,U0003,Cov-19 amp prb hgh thruput,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,U0004,Cov-19 test non-cdc hgh thru,Lab Services,Per Unit,$75.00 ,OP,75,75,,,,,,,,,,,,
United Healthcare VA PC3,CPT,U0005,Infec agen detec ampli probe,Lab Services,Per Unit,$25.00 ,OP,25,25,,,,,,,,,,,,
United Healthcare VA PC3,,,,All Other,Straight Discount,30.00%,OP,,,,,,,,,,,,,,